COVID-19 Pre-Registration Form
Ebenezer AME Church is currently partnering with Prince George's County as a COVID-19 mobile vaccine site.

Please complete this vaccine pre-registration form to start the registration process. After submitting this initial form, you will be provided with a link to complete your registration with the Prince George's County Health Department.

*Please note that completion of this registration does not guarantee access to receive a vaccine. Vaccine availability and scheduling will be conducted by the Prince George's County Health Department.
Full Name *
Telephone Number *
Email Address *
Date of Birth *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy