St. Padre Pio Parish COVID-19 Vaccine Clinic
Patient Registration Form. Once registered, a volunteer will call or email with your confirmed appointment time.

Clinic Date: December 17, 2021 3 pm - 7 pm

Church Rectory
St. Padre Pio Parish at St. Hilary’s
5600 N Fairfield Ave, Chicago, IL 60659

Questions? Ask JP Jael (708-717-8283) or Iam Calsita (773)-561-3474

For more information about COVID-19 vaccines, please visit the websites below

Sign in to Google to save your progress. Learn more
Email *
Name  (ex. JP Jael) *
Phone Number (ex. 773-555-5555) *
Age *
Preferred vaccine (ages 12+ only) *
Preferred appointment times (15 minute appointments) *
Preferred language *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Filipino Young Leaders Program. Report Abuse