Mt. Oliver: Vaccine Registration Form

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Bethany Community Ministries is hosting a 2nd COVID-19 Vaccination Event at Mt. Oliver Fire Station in partnership with Allegheny Health Network and PCHS. Please complete this form to pre-register for the event. Children under 18 must be accompanied by an adult to receive the vaccine.

Event Date: Saturday, March 26, 2022
Location: Mt. Oliver Fire Station
120 Brownsville Road, Pittsburgh, PA 15210
Time: 10:00 AM to 12:00 PM
Eligibility: Ages 5+
Cost: FREE

Get $25 from BCM if you're one if the first 150 vaccinated!

Vaccines Available:
- Pfizer (2-step): Ages 5 & up
- Moderna (2-step): Ages 18 & up
- Johnson & Johnson (1-step): Ages 18+

First Name *

Last Name *

Phone Number *

Phone Type *

Cell Phone

Home Phone

Email Address *

Zip Code *

Date of Birth *

YYYY

Race *

Black / African-American

White / Caucasian

Asian (not Pacific Islander)

Indigenous American / Alaska Native

Latino / Latina

Multi-Racial

Other:

Required

Ethnicity *

Hispanic

Non-Hispanic

Gender *

Male

Female

Non-Binary

Other:

Who is your insurance provider?

Aetna

Gateway

Highmark Wholecare

UPMC

None

Other:

Clear selection

Which vaccine do you want to receive?

Pfizer

Moderna

Jensen

Clear selection

Which dose will you be receiving?

1st COVID vaccine dose

2nd COVID vaccine dose

Booster Dose

Clear selection

Submit

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