COVID-19 Vaccination Request Form

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¿española? http://bit.ly/asistenciadevacuna

**Interested in volunteering? Fill out this form! https://forms.gle/AnMFBtJe1YYAj2Ns5 **

We're VaxForce - a small but mighty group of tech-savvy millennials helping eligible folks schedule Covid-19 vaccine appointments.

We will be continuously monitoring vaccine distribution sites including Kroger, Walmart, Walgreens, CVS, Ralph's, HEB, County Health Department hubs, local health clinics, and hospitals. As soon as an appointment becomes available in your area, our team will immediately use this information to try and reserve an appointment slot.

We'll only share your information with other volunteers to facilitate appointment scheduling. We will never sell your information. However, please be advised this information is not secured.

Please note that we cannot guarantee appointments and all appointments are first-come, first-served. This should not replace your efforts, but rather should be used to support your own efforts.

KNOW BEFORE YOU GO:

Before booking an appointment for the COVID-19 vaccine, it is important to know current health and safety recommendations from the CDC. Please make sure you have consulted a medical professional to ensure it is safe for you to receive the vaccine.

Please make sure you have reviewed the following documents before requesting an appointment:
Pfizer - https://www.fda.gov/media/144414/download
Moderna: https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf

We are only booking for people who qualify for the vaccine in their county. Please review your county guidelines and select the applicable option below: *

ATTENTION: If you are not eligible, please DO NOT FILL OUT THIS FORM. It clogs the system and takes valuable time away from those who are eligible. Feel free to reach back out when you are eligible, but do not ask us to make an appointment if you do not meet the criteria.

I am 65+ (or otherwise meet my county's minimum qualifying age)

I am a healthcare worker

I have a chronic condition that qualifies me

I am a frontline essential worker (that is eligible according to my state at this time)

Required

First Name *

Last Name *

Date of Birth *

YYYY

Best Phone Number *

It can be the recipient's or a relative or friend - put the best # for us to communicate about scheduling.

Best Email Address *

It can be the recipient's or a relative or friend - put the best email for us to communicate about scheduling.

Street Address *

ex. 123 Main St., Apt 5

City *

State *

Zip Code *

County

(if known)

Logistics for appointment. Check if Yes.

Yes

Non-English speaker?

History of anaphylaxis? (e.g. you carry an EpiPen)

Requester Name & Relationship *

Ex. Anna, daughter. If requestor is the recipient, please write "Self"

Anything else you'd like us to know?

How did you hear about us?

Facebook

Word of Mouth

Media

Episcopal Diocese

Other:

VaxForce Guidelines *

I understand that VaxForce cannot cater to preferences of Pfizer v. Moderna v. J&J and I will be okay with any vaccine brand.

I understand that appointments cannot be rescheduled or transferred and if I cancel, VaxForce will need to start the process over again and may not be able to secure another appointment.

I will email VaxForce at vaccineassist@gmail.com if I find an appointment so my volunteer won't double book one.

Required

Liability Release

I hereby release, acquit, and forever discharge participants in the LA County Covid-19 Vaccination Assistance Program ("VaxForce") and its subsidiaries and affiliates and its and their present and former directors, officers, employees, agents, volunteers, and representatives and the respective heirs, administrators, executors, successors and assigns (collectively, the "Parties" or individually, a "Party") from any and all claims, causes of action, suits, demands, settlements, judgments and/or expenses (including, but not limited to, reasonable attorneys’ fees) for any and all injuries accrued or to accrue in the future, known or unknown, (collectively, "Claims") relating to or arising out of any negligent acts in connection with his/her entry into and participation in the LA County Covid-19 Vaccination Assistance Program, including but not limited to the negligent actions of the parties, regardless of whether such negligence was the sole, proximate, or producing cause of the claims. Without limiting the foregoing, the undersigned agree that the Parties shall not be liable to him/her, his/her family, heirs, administrators, executors or assigns for Claims arising from or related to the undersigned's entry into and participation in the Activities. I hereby certify that the recipient has reviewed the Pfizer and Moderna Information Sheets provided above and consents to the LA County Covid-19 Vaccination Assistance Program scheduling an appointment on their behalf. *

I have read the above terms and conditions and I agree.

Required

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