PACT KPT Offices - HMHB Vaccine Clinic Pre-Registration (November 17 & 18)

Central Union Church - HMHB Vaccine Clinic Pre-Registration (Sunday, November 20th)

Please complete this pre-registration form, and BRING YOUR VACCINE CARD AND A CONSENT FORM (hard copy) for each individual interested in receiving a vaccine! This is to ensure an accurate count for the amount of doses needed for the event.
Full Name
Phone Number

Area CodePhone Number
Date of Birth

DayMonthYear
E-mail Address
Which vaccine(s) would you like to receive at the event? You are able to receive BOTH the flu shot and the COVID vaccine at the same time if you'd like!
Please select the DATE and TIME you would like to attend the vaccine clinic. HMHB will be at Central Union Church at the Punahou Parking Lot (12:00 PM - 2:00 PM).
Should be Empty:

Central Union Church - HMHB Vaccine Clinic Pre-Registration (Sunday, November 20th)