Free Community Vaccine Clinic at the The Franklin Institute

COVID-19 Vaccine Registration Form
Free Community Vaccine Clinic at The Franklin Institute, hosted by Art-Reach, PHMC, Chinatown Disability Advocacy Project, and Rite Aid with special guest Congressmember Dwight Evans. The Vaccine Clinic will take place on Monday, May 10th 2021. We are offering the Moderna vaccine for Individuals 18 or Older.
Which of these applies to you?

I live or work in PhiladelphiaI do not live in Philadelphia, but I do work in Philadelphia and would like to be vaccinated
Have you ever received a dose of COVID-19 vaccine?

YesNoI do not know
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender at birth*
Race*
Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

InsuredUninsured
Insurance Provider
Insurance ID Number
Do you need an Interpreter? If you have chose yes, please select preferred language below.
Preferred Language
Do you have allergies? If so please list them here*
Are there any other considerations you want us to be aware of? If so please list them here
Preference of Time

10:00am - 12:00pm12:00 pm -2:00 pm2:00pm - 4:00pm
Please read and confirm*

I affirm that I have answered these questions truthfully and to the best of my knowledge and acknowledge that I may be asked to verify my eligibility information at my appointment.
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COVID-19 Vaccine Registration Form