COVID-19 Vaccine Program for any Adults in Santa Cruz County
These clinics, are a partnership with the Santa Cruz County Office of Education and several medical providers. A registrants must be 18 or older and are required to be available for the 2nd dose exactly 3-weeks from their first dose for Pfizer vaccine.
Sign in to Google to save your progress. Learn more
What is your First Name / Cual es su Primer Nombre *
What is is your Last Name / Cual es su apellido *
Phone Number *
Email / Correo Electronico
What is your Date of Birth / Fecha de Nacimiento (must be 18 or older / Necesita tener 18 años o mas) *
MM
/
DD
/
YYYY
Name of the Organization you work for / Nombre de la organizacion por la cual trabaja *
Type of Work / Tipo de trabajo *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Santa Cruz County Office of Education. Report Abuse