Covid Survey

Covid Survey
your name
First and Last Name
Phone Number*

Area CodePhone Number
Date of Completion*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
JCOA is offering COVID-19 vaccinations at the Senior Centers. Would you like to receive a vaccination?

YESNO
Tell us the COVID-19 shot you need

First ShotSecond ShotBooster
Do you need transportation to the Senior Center?

YESNO
Are you a member of a JCOA Senior Center?

YESNO
If so, which one?
If no, would you like to become a member?

YESNO
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