Register for the FREE Vaccine Clinic at the Ward Y in Abingdon

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The Ward Y in Abingdon, located at 101 Walter Ward Blvd., Abingdon, MD 21009, is hosting a free community vaccine clinic in partnership with Weis Markets. The Pfizer vaccine will be administered. You must be 12 years of age or older to participate.

If you would like to receive the vaccine, please submit the form below to register for both your 1st and 2nd vaccine dose.

1st dose: Tuesday, September 28, 9am - 12pm, 3pm - 6pm
2nd dose: Thursday, October 21, 9am - 12pm, 3pm - 6pm

First Name *

Last Name *

Address including City, State and Zip Code *

Phone Number (xxx-xxx-xxxx) *

Date of Birth (mm/dd/yyyy) *

Are You a Y associate? *

Yes

Preferred Time *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of The Y in Central Maryland.

Does this form look suspicious? Report

Forms