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
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.
* Indicates required question
Name (ex. JP Jael)
Phone Number (ex. 773-555-5555)
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)
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Filipino Young Leaders Program.