Request edit access
JFSA COVID-19 Vaccination Registration
Jewish Family Service Association of Cleveland (JFSA) is proud to partner with Anshe Chesed
Fairmount Temple, Congregation Shaarey Tikvah, Beth Israel - The West Temple, the Mandel Jewish Community Center and other Cleveland-area synagogues and organizations to coordinate a series of free COVID-19 vaccination clinics for anyone ages 12 and up. With help from the Jewish Federation of Cleveland and volunteer organizations Serve the Moment and Cleveland Vaccine Volunteer Network, JFSA will run pop-up Pfizer vaccine clinics throughout the summer.

Please fill out this form with your preferences for vaccination location and time. Be prepared to bring a photo ID and your insurance card (insurance is not required to get a vaccine). Vaccination is free of charge. We will be offering the Pfizer vaccine.

If possible, print and fill out the Ohio Department of Health Form linked here:
Please bring it with you on the day of your appointment.

There will be complimentary snacks provided after vaccination! Transportation assistance is also available.
Sign in to Google to save your progress. Learn more
How did you hear about our clinic? *
First Name *
Last Name *
Phone Number *
Date of Birth *
You must be age 12 or older on the day of vaccination to receive the vaccine.
Street Address, City, Zip Code *
Gender *
Race *
Ethnicity *
Do you need assistance with transportation? *
We are able to provide bus passes/lyft/uber rides upon request.
Preferred Date and Location *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Repair the World. Report Abuse