Vaccine Sign-up Form

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VACCINE SIGN-UP FORM

Get your COVID-19 shots, flu shots, and more!
SUNDAY, August 27, 2023

1:00 PM -4:00 PM

Vietnamese Alliance Church

2130 N. Grand Ave., Santa Ana, CA 92705
Your Contact Information:*

PrefixFirst NameMiddle NameLast Name
Cell Phone Number (can receive text messages)*
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
E-mail
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Information About Your Household*
Select Your Appointment for Food Pick-Up*
One appointment per family for food pick-up. Valid photo ID is required upon check-in.
Hepatitis B & C (Blood draw, no fasting needed)Tuberculosis (Blood Draw, no fasting needed)Colorectal cancer (FIT Kit)
Flu shotCOVID-19 shot
First COVID-19 shotSecond COVID-19 shotCOVID-19 updated vaccine (bivalent)
PfizerModernaAny
YesNo
Health Insurance - Member ID
Health Insurance - Group number
Health Insurance - RxBIN
Health Insurance - RxPCN number
YesNo
If answered "Yes" in the question above, please provide the name the person/organization that helped you:
Comments or Questions:
VACF will confirm the appointment with you via email or text message. Please check your Spam/Junk Mailbox.
Should be Empty:

VACCINE SIGN-UP FORM