JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Vaccine Clinic Sign Up Form
Thank you for signing up. You will receive a call from us.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Email
*
Your answer
Address (Street, City, ZIP)
*
Your answer
Are you a resident of Adams County and have proof? (i.e. utility bill, signed lease, pay stub, etc.)
YES
NO
Phone number
Your answer
Do you identify as a BIPOC person (Black, Indigenous, Person of Color?
*
YES
NO
Required
Which community do you identify yourself as a member of?
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Two or more races
Other:
Clear selection
How many members of your household will need an appointment for a vaccine?
1
2
3
4
Other:
Clear selection
Are all household members seeking a vaccination older than 12 years of age?
YES
NO
Are you scheduling this appointment for a child who is aged 5 to 12 years of age? Please note the Pfizer vaccine is the only one available for this age group.
YES
NO
Which vaccine do you prefer?
Pfizer (available for ages 12+ up)
Moderna
Other:
Comments
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
