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Philippine Red Cross - Moderna Vaccination Pre-Registration
Thank you for your interest in the Philippine Red Cross Moderna Vaccination Program. To pre-register, please kindly fill up this form. We will be in touch in due time.
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Email
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Your email
Name
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Your answer
Company/Organization, if any
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Birthday
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MM
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DD
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YYYY
Mobile Number
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Your answer
Occupation
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Your answer
DOH Priority Group
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Choose
A1 (Workers in Frontline Health Services)
A2 (All Senior Citizens)
A3 (Persons with Comorbidities)
A4 (Frontline personnel in essential sectors, including uniformed personnel)
A5 (Indigent Population)
B1 (Teachers, Social Workers)
B2 (Other Government Workers)
B3 (Other Essential Workers)
B4 (Socio-demographic groups at significantly higher risk other than senior citizens and poor population based on the NHTS-PR)
B5 (Overseas FIlipino Workers)
B6 (Other Remaining Workforce)
C (Rest of the Filipino population not otherwise included in the above groups - including students)
Number of Doses
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Your answer
Comorbidities (if any)
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Terms and Conditions
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By filling up this form, I acknowledge that accomplishing this form is a means to stay up to date rather than guarantee a slot in the Philippine Red Cross Moderna Vaccination Program. The Philippine Red Cross is free from any liability and/or obligations.
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Data Privacy Consent
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I give my consent to the collection, process, and use of my personal data in accordance with the Data Privacy Act of 2012 (Republic Act No. 10173).
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A copy of your responses will be emailed to the address you provided.
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