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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
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/keythingstoknow.html
https://www.tayohelp.com/hc/en-us
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* Indicates required question
Email
*
Your email
Name (ex. JP Jael)
*
Your answer
Phone Number (ex. 773-555-5555)
*
Your answer
Age
*
12-17 years
18-50 years
50-64 years
65+ years
Preferred vaccine (ages 12+ only)
*
Pfizer (Adolescent - Adult 12+ years only)
Jonson and Johnson (18+ years only)
Moderna (16+ years only)
Preferred appointment times (15 minute appointments)
*
3:00-3:15 pm
3:30-4:00 pm
4:00-4:30 pm
4:30-5:00 pm
5:00-5:30 pm
5:30-6:00 pm
6:00-6:30 pm
6:30-7:00 pm
Required
Preferred language
*
English
Tagalog
Cebuano
Spanish/Español
Other
Required
A copy of your responses will be emailed to the address you provided.
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