COVID-19 Test Kit Distribution Survey

New Vision has received a limited supply of "iHealth Antigen COVID-19 Home Test Kits" from the State of Connecticut to distribute to our community.

The purpose of this survey is to gauge your interest in order to plan an effective & orderly distribution on Sunday, January 30th immediately following service and Tuesday, February 1st from 11am to 2pm.

The completion of this form does not guarantee receipt or reservation of a kit, given the high demand and limited supply.

We will distribute the kits until our supply for the day is exhausted.

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Telephone Number *

Email *

example@example.com

Are you a member of New Vision? *

yes no

How many COVID-19 Home Test Kits will you need? Please note: Only one (1) COVID-19 HOME TEST KIT PER INDIVIDUAL FOR YOUR IMMEDIATE HOUSEHOLD ONLY - limit six (6) *

1 2 3 4 5 6

Please list the names and ages of the family members in your immediate household. *

iHealth COVID-19 Home Test Kits will be available Sunday, 1/30/22 and Tuesday, 2/1/22 from 11:00 AM to 2:00 PM. Please check off the date and time you plan to pick-up your test kits. Please only choose one date for pick up: *

I will pick up my COVID-19 test kits Sunday, 1/30/22 immediately following service I will pick up my COVID-19 test kits Tuesday, 2/1/22 at the following time: 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM

I understand that COVID Home Test Kits are in limited supply and are distributed on a "first come basis." I also understand that the completion of this form does not guarantee receipt or reservation of a kit, given the high demand and limited supply. *

Clear