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Vaccine Clinic Sign Up Form
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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:
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