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 Name Last Name
Date of Birth *

Month Day Year
Date
Sex *

Male Female Non-Binary Prefer not to answer
Age *
Phone Number *

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

Yes No
Address

Street Address

Street Address Line 2

City State / Province

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

Yes No
Occupation
Select the age range that applies to you.

5-15yrs 16-25yrs 26-35yrs 36-45yrs 46-55yrs 56-65yrs 66-75yrs 76-85yrs 86-95yrs
Comments
Vaccination Site
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COVID-19 VACCINATION WAITLIST