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!*

Flu ShotPfizer - Bivalent Booster (12+ years old)Moderna - Bivalent Booster (6+ years old)Pediatric Pfizer - Bivalent Booster (5 - 11 years old)Pfizer - Initial Series (12+ years old)Moderna - Initial Series (18+ years old)Pediatric Pfizer - Initial Series (5 - 11 years old)Baby Pfizer - Initial Series (6 months - 4 years old)Baby Moderna - Initial Series (6 months - 5 years old)
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)