Hays Manor Vaccine Registration Form
Bethany Community Ministries is hosting a COVID-19 Vaccination Clinic at Hays Manor Community Day in partnership with the Black Equity Coalition, Highmark, Allegheny Health Network, and PCHS. Please complete this form to pre-register for the event. Children under 18 must be accompanied by an adult to receive the vaccine.

Get $50 from BCM when you pre-register and get your COVID vaccine!

Vaccines Available:
- Pfizer (2-step): Ages 5 & up
- Moderna (2-step): Ages 18 & up

Date: Tuesday, August 30, 2022
Location: Hays Manor Community Day
205 Locust Street, McKees Rocks, PA 15136
Time: 4:00 pm to 7:00 pm
Cost: FREE!
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First Name *
Last Name *
Phone Number *
Phone Type *
Email Address *
Zip Code *
Date of Birth *
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Race *
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Ethnicity *
Gender *
Who is your insurance provider? *
Which vaccine do you want to receive? *
Which dose will you be receiving? *
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