Calling all the shots! “You have a spot. Take your shot”!

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please sign up and our staff will coordinate and date and time. For any questions, please call Janma at 336-540-4082, Satta at 302-444-7026, Marthalenar at 336-529-5012, Ysiu at 336-301-7504, and Pastor Prince at 336-455-4290.

Partners: CCC of NC, Ysiu, Pastor Prince, Janma, Satta, and Mathalenar.
—
MDA/MAO
611 Summit Ave Suite 10
Greensboro, NC 27405
Montagnardda.org

Last Name *

First name *

DOB (mm/dd/year) *

Full Address *

Gender *

Female

Male

Non-binary

Other

Phone number *

What language do you speak? *

Covid Vaccine or flu shot *

1st dose (covid vaccine)

2nd does (covid vaccine)

Booster shot (3rd dose covid vaccine)

Flu shot

Medorna booster (3rd dose covid vaccines)

Children 5-11 years old

Date of your 2nd or 3rd dose

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms