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Vaccine Registration Form
Full Name
*
First Name
Middle Name
Last Name
Birth Date
*
-
Month
-
Day
Year
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Sex (assigned at birth)
*
Female
Male
Gender Identity
Male/Man
Female/Woman
Prefer not to say
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Race
*
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Black or African American
Asian
White
Phone Number
*
Please enter a valid phone number.
Can we call and leave a message?
*
Yes
No
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you insured?
*
Yes
No
Insurance Company
Put "none" if not applicable
Insurance ID
Put "none" if not applicable
Social Security Number
Which vaccine would you like to register for?
*
COVID-19
Flu
Both COVID-19 and Flu Vaccines
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Health and Medical History
COVID-19 Vaccine screening
Is this your first time receiving the COVID-19 vaccine?
*
Yes
No
If no, have you had a serious reaction to the COVID-19 vaccine in the past?
*
Yes
No
Not applicable
Which COVID-19 vaccine(s) did you receive (if any)?
*
Pfizer-BioNTech
Moderna
Janssen (Johnson & Johnson)
Novavax
Not applicable
Other
How many COVID-19 vaccines have you received prior to today?
*
Put "none" if none
When did you last receive a COVID-19 vaccine?
*
-
Month
-
Day
Year
Date Picker Icon
Do you have any chronic health conditions? (Write none if not applicable)
*
Please indicate all health issues that are considered within the risk group
Have you recently been diagnosed with COVID-19?
*
Yes
No
If yes, please provide further details (date of diagnosis, were you hospitalized or not, treatment, etc.)
Are you currently experiencing any of the following?
*
Loss of taste or smell
High fever
Difficulty breathing
Body aches
Runny nose
Diarrhea
Cough
Persistant pain or pressure on chest
Nasal congestion
Sore throat
None
Which location/event would you prefer to receive the COVID vaccine?
Examples: NJCU, Heavenly Temple, Grace Senior Center, etc.
I hereby declare that the information I have provided is accurate
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Health and Medical History
Influenza Vaccine Screening
Have you received any vaccinations in the past month?
*
Yes
No
If yes, please state which vaccines you have received in the past month
Have you had a serious reaction to the influenza vaccine in the past?
*
Yes
No
Not applicable
Please list your allergies, write "none" if none
*
Do you have any chronic health conditions? (Write none if not applicable)
*
Please indicate all health issues that are considered within the risk group
Are you currently experiencing any of the following?
*
Loss of taste or smell
High fever
Difficulty in breathing
Body aches
Runny nose
Diarrhea
Cough
Persistant pain or pressure on chest
Nasal congestion
Sore throat
None
Which location/event would you prefer to receive the Flu vaccine?
Examples: NJCU, Heavenly Temple, Grace Senior Center, etc.
I hereby declare that the information I have provided is accurate
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Verify Information & Submit
Sign verification that the information you have provided to this form is accurate and then select "Register" to submit this form.
Which event/location would you like to receive the vaccines?
*
Examples: NJCU, Heavenly Temple, Grace Senior Center, etc.
I hereby declare that the information I have provided is accurate.
*
Register
Register
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