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

Clinic Dates: June 27 1st dose (Pfizer or J&J), July 18 2nd Dose (Pfizer)

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

Email *
Name (ex. JP Jael) *
Phone Number (ex. 773-555-5555) *
Age *
Preferred vaccine *
Preferred range of time (15 minute appointments) *
Required
Preferred language *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Filipino Young Leaders Program. Report Abuse