Durham’s COVID-19 Vaccination Waitlist

COVID-19 VACCINATION WAITLIST

DURHAM’S OUTREACH CENTER
Disclaimer
- Durham Memorial AME Zion Church is a religious institution.
- The medical professionals are NOT affiliated with Durham Memorial Church.
- All participants must live within the 14204 area code.
What is your health insurance company’s name:
ID/Policy Number:
Promotional Code
3 Digit Code
Name:

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemaleNon-BinaryPrefer not to answer
Age*
Phone Number*

Area CodePhone Number
E-mail
Race/Ethnicity
Do You live in the State of New York?*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do You work in the State of New York?*

YesNo
Occupation
Select ALL that apply

Age 50+Healthcare personnelTeachers & Child Care WorkersPublic Transit WorkersGrocery Store WorkersHotel WorkersPeople with Qualifying Comorbidities & ConditionsResidents & Staff at Long Term Care FacilitiesResidents & Staff in Congregate SettingsFirst Responders & Corrections WorkersRestaurant Workers & Restaurant Delivery WorkersFor-Hire Vehicle DriversIn-Person College Faculty & Essential StaffPublic-Facing Government/Public EmployeesPublic-Facing Not-For-Profit WorkersEssential In-Person Building Service WorkersOther
Please visit the website listed below to see full eligibility list: https://covid19vaccine.health.ny.gov/phased-distribution-vaccine#phase-1a---phase-1b

Add any that relate to you in the 'Other' space above.
Comments
Vaccination Site
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COVID-19 VACCINATION WAITLIST