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COVID-19 Vaccine Clinic Pre-registration
Event Timing:
Friday, September 30th 8:00 am to 12:00 pm
Event Address:
225 Penn Ave. Pittsburgh, PA 15221
*If you need to register for an additional person (child, spouse, etc.), please fill out a separate form for each person!
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* Indicates required question
I am filling out this form for...
*
Myself
My child
Spouse/Partner
Family Member
Other
Other:
First Name
*
Your answer
Last Name
*
Your answer
Email Address
Your answer
Age of Person Receiving Vaccine
*
6 months-4 years old
5-11 years old
12-17 years old
18-50 years old
50+ years old
Are you interested in receiving a flu vaccine?
*
Yes
No
Maybe
Have you or your child received a COVID-19 vaccine before?
*
Yes
No
What type of vaccine did you/your child receive?
Moderna
Pfizer
Johnson & Johnson
Unsure
How many doses have you/your child received?
*
None (have never had a COVID-19 vaccine)
One (First Dose)
Two (Second Dose)
Three (Two Doses + First Booster)
What type of vaccine would you prefer to receive?
Moderna (mRNA)
Pfizer (mRNA)
Novavax (Protein-based) [only available for those 18+]
Clear selection
Would you like to receive monthly emails from the Pennsylvania Immunization Coalition (PAIC)?
Yes
No
Clear selection
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