CCACC At-Home Rapid Test Kits Pre-register 新冠病毒居家試劑預先登記表

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Please fill out the form below to reserve your kits, and contact us at 240-393-5950 to make an appointment for pick up. 請填寫表格，並致電240-393-5950 預約領取時間。

First Name 名 *

Last Name 姓 *

Email 電郵

Phone number 電話

Zipcode 郵政編碼

Race 種族 *

Asian 亞太裔

African American

White

American Indian or Alaska Native

Native Hawaiian and Other Pacific Islander

Some other Race

Other:

Occupation 職業 *

Childcare provider 育兒工作者

Construction worker 建築業

Grocery store or food service worker 賣場或餐飲業員工

Manufacturer worker 製造業

Healthcare worker 醫療業

Education worker 教育業

Unemployed 無職業

Student 學生

Other:

Do you speak 請問您能說下列幾種語言 *

English 英文

Chinese 中文

Spanish 西文

French 法文

Other:

Required

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