Whose House? GOD's House: Vaccine Pre-Screening for Parishioners
The following information will be utilized as a faith-based community effort to provide additional vaccination sites for members of our church community. Please complete ONE form for EACH person desiring to get vaccinated. We will be in touch with you regularly through text messages and emails.
Email *
Your Last Name *
Your First Name *
Contact Email Address *
Contact Phone Number (where you can receive text message updates) *
Your Street Address *
City
Zip Code *
Name of Church Affiliation *
City where your church is located? *
Are you signing up for the COVID vaccine through this site? *
According to State of Maryland guidelines, which category(s) do you fit into? Check all that apply to you. *
Required
Do you need transportation to or from a vaccination site? *
If you are a healthcare professional, select all that apply.
Volunteers please check all that apply: *
Required
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy