In-Home Vaccination Request

In-Home Vaccination Request
KC Shepherd's Center is excited to partner with the KC Fire Department's Medical Response Team and Core Lab Solutions to offer the COVID-19 vaccine in the home for older adults who are homebound. If you or someone you know lives in the Kansas City Metro and needs the COVID-19 vaccine please complete this form and the KCFD or Core Lab Solutions will contact you to schedule the vaccination.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
If you are completing this registration for someone else, please, provide your name and contact information.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
YesNo, contact the recipient
Comments
Should be Empty: