Durham’s COVID-19 Vaccination Sign up

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.
Address:

Durham's Outreach Center Inc.
200 E. Eagle Street
Buffalo, NY 14204

ALL ARE WELCOME! (Walk-in's are also welcome!!)
What is your health insurance company’s name:
ID/Policy Number:
Promotional Code
3 Digit Code
Name:

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Age
Phone Number

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do You work in the State of New York?
Occupation
Select the age range that applies to you.

Other
Comments
Vaccination Site
Should be Empty: