WAIT LIST FOR COVID-19 VACCINATION CLINIC (FEB. 13-16,2021)

THIS IS A WAIT LIST FOR THE COVID 19 VACCINATION CLINIC.  Please check your email throughout this week to see we have leftover vaccines, we will let you know.  This Saturday, Feb. 13, 2021, we are offering the COVID vaccine at two locations.  NOTE:  In order for us to give you appointment for the leftover vaccine, we must have your information so we can enter it into the State’s COVID vaccine system (CVMS).  This way, when we notify you for the appointment, we have everything ready to go.  ALL of our COVID Vaccine Clinics are by appointment ONLY.  PLEASE DO NOT CALL US.

First name: ^*

Last name: ^*

Email: ^*

Home xxx-xxx-xxxx: ^*

Cell phone xxx-xxx-xxxx: ^*

Street: ^*

City: ^*

State: ^* AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY

ZIP (12345): ^*

Date of Birth (mm/dd/yyyy): ^*

Race: ^* -Select One-American Indian or Alaska NativeAsianBlack/African AmericanNativeHawaiian or Pacific IslanderWhiteOther RaceDeclined to answer

Ethnicity: ^* ----Hispanic or LatinoNot Hispanic or Latino

Sex: -Select One-MaleFemaleDeclined to Answer

How did you know about us?: ^* -Select One-Declined to answerI do not go to churchChristian ChurchCatholic ChurchSt. Ann Catholic ChurchSt. Joseph Primary CARESt. Joseph Catholic ChurchSt. Francis of Assis Catholic ChurchSt. Luke Catholic Church, RaleighSt. Eugene Catholic ChurchSt. Michael the Archangel Roman Catholic ChurchSt. Catherine of Sienna Catholic Church, Wake ForestHoly Name Of Jesus CathedralOur Lady of Lourdes Catholic ChurchOur Lady of Lavang Catholic Church, RaleighOur Lady of Rosary Catholic Church, LouisburgMaria, Reina de las Americas Catholic Church, Mt. OliveSt. Joseph Catholic Church, Vietnamese Church in CharlotteVan-Hanh Pagoda-NC BuddhistSt. Matthew Baptist Church, RaleighVietnamese Raleigh CommunityFrom a friendSocial Media

Is this your 1st dose of COVID19 vaccine?: ^* ----NoYesNot sure

Allergic to vaccine?: ^* ----NoYes

Being vaccinated with another vaccine?: ^* ----NoYes

Bleeding disorder?: ^* ----NoYes

Received monoclonal antibodies?: ^* ----NoYes

Severe allergic reaction?: ^* ----NoYes

Severe allergy to any ingredient?: ^* ----NoYes

Tested positive for COVID-19?: ^* ----NoYes

Weakened immune system or pregnant?: ^* ----NoYes

Number of health conditions?: ^* -select one-12none

Type the text shown: *

^* These fields are required.