Vaccine Sign-up Form (AHS)

First Name

Middle Name

Last Name

Male/Female

Date of Birth

mm/dd/yyyy

Ethnicity

Race

Telephone #

Email Address

The registered individual will be notified via email the day before the vaccine clinic, if there are available doses. This will be the only notification that will be received.

Address

Apartment # / Building #

City

State

Zip Code

County

Mother's First Name

Mother's Maiden Name

Are you a healthcare worker identified on the 1a priority list for vaccines?

Yes

Are you 50 years or older?

Yes

Do you have a health conditions that puts you at risk for COVID-19 complications?

Yes

Are you a HMC employee (receive check from HMC)

Yes

Do you work for a school district or child care provider?

Yes

School District

Allergic Reaction

Yes

Don't Know

I have read the following

I have received the FDA fact sheet for patients and parents/caregivers, which includes information on potential risks, benefits, purpose, side effects, dosing methods, and alternative treatment choices for the vaccine. I have been informed that the vaccine is an unapproved vaccine that may prevent COVID-19. There is no FDA_approved vaccine to prevent COVID_19 but the vaccine has received Emergency Use Authorization (EUA) from the FDA.

I have read the following

Signature

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Send me a copy of my responses

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