COVID Vaccination Support - 1C
While we are blessed and grateful that the COVID vaccine is now available, we know there are many challenges with securing appointments and getting to appointments. B'nai Jeshurun is pleased to have organized this initiative to provide support in securing vaccination appointments. Please fill out this form and let us know your needs, so that we can best organize volunteers from the B'nai Jeshurun community and beyond to assist you.

PLEASE NOTE: we have limited volunteer capacity, and are deploying our volunteers to assist those who are facing significant difficulty in making an appointment on their own. If you are tech savvy/comfortable on the computer, or if you have family or friends who can assist you, please do not request the support of our volunteers. Thank you!
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First Name *
Last Name *
Email *
Phone number *
Your age *
Are you a BJ member? *
Please click here to affirm that you are eligible for the vaccine, per New York State guidelines, and have (or will obtain) appropriate documentation. https://www.governor.ny.gov/news/governor-cuomo-announces-new-yorkers-comorbidities-and-underlying-conditions-can-make *
In what borough do you live? *
What is your zip code? *
How far are you willing to travel for an appointment? (Although we will do our best to accommodate your ideal location, we cannot guarantee an appointment in any particular location. The more you are able to be flexible on location, date and time, the faster we may be able to secure an appointment on your behalf.) *
Please let us know what support would be helpful to you *
Required
How did you hear about this support initiative? *
Required
Personal information such as date of birth and social security number may be required in order to make an appointment. This information will only be used to help schedule the appointment and will be kept in confidence. Are you willing to provide this information to a volunteer so they can make the appointment on your behalf? *
Please note that B’nai Jeshurun and any volunteer assisting you in connection with your request for assistance is unqualified and unable to provide you with any medical advice, guidance or diagnosis.  Accordingly, while we will do our best to assist you in securing an appointment for the Covid vaccine, you acknowledge and agree that you will not rely upon any information you receive from us as medical advice. Please speak to your doctor in connection with any medical or health questions or concerns that you may have, including, whether you qualify for the vaccine or otherwise whether you need to be aware of any potential adverse reactions. Additionally, by responding 'yes' to this question, you affirm your understanding that you are obtaining the vaccine at your own request and at your own risk and in no event will B'nai Jeshurun or any volunteer be responsible in connection with any adverse effects that may occur as a result of the vaccine. *
Please share any additional information, or questions in the space below. If you do not have questions or information to share, simply click 'Submit'
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