Self-Service Vaccination Request
Martin Luther King Jr. Technology Academy – Gym – 3051 Fairfield Street, Sacramento, CA 95815
MUST BRING PROOF OF BIRTHDATE
NOTE: If you are making a 1st dose appointment for Friday, July 23rd. Your return will be on August 23rd. You do not need to make an appointment, you can also go elsewhere for your 2nd dose: https://myturn.ca.gov/
RegDate
.
Year
.
Month
Day
First Name
*
Last Name
*
Date of Birth
*
/
Month
/
Day
Year
Gender
*
M
F
U
Street Address
City
Zip Code
*
Mobile Number
*
Format: (000) 000-0000.
Ethnicity
*
2135-2 : Hispanic or Latino
2186-5 : Not Hispanic or Latino
UNK : Unknown Ethnicity
Race
*
1002-5 : American Indian or Alaska Native
2028-9 : Asian
2054-5 : Black or African American
2076-8 : Native Hawaiian or Other Pacific Islander
2106-3 : White
2131-1 : Other Race
UNK : Unknown
Tier
*
Phase 1a - Tier 1 : acute care; psychiatric hospital staff; nursing staff, assisted living facility; long-term care residents; emergency medical services; dialysis centers
Phase 1a - Tier 2 : intermediate care facility; home healthcare staff; community health workers; public health staff/medical services; urgent, primary, & rural care clinics
Phase 1a - Tier 3 : specialty clinics; lab workers; dental care staff; pharmacy staff
Phase 1b - Tier 1 : individuals 12+ years old who live or work in Sacramento County
Dose
*
1st Dose
2nd Dose
1st Dose Date
/
Month
/
Day
Year
E-mail
for email confirmation and follow-up
Language Preference
English
Spanish
Hmong
Vietnamese
Other
Appointment
*
Appointment Date
/
Month
/
Day
Year
AM
PM
AM/PM Option
Submit
Should be Empty: