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Vaccine Clinic Registration form
Renton KEC Building October 28th, 2024 3pm-6pm
COVID VACCINES, ROUTINE CHILDHOOD VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS. NO INSURANCE NECESSARY.
First Name
Last Name
Sex
Male
Female
Gender Identity
Male
Female
Non-Binary
Other
Date of Birth
-
Month
-
Day
Year
Date
Parent/Caregiver's Name
Relationship to the patient
Email Address
Phone Number
Street Address 1
Street Address 2
City
State
Zip Code
Racial Identity
White
Black
Asian
Native Hawaiian or Pacific Islander
American Indian/Alaska Native
Other
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Insurance Provider *INSURANCE IS NOT REQUIRED*
Premera
Regence BCBS
Blue Cross Blue Shield
Molina Apple Health
Molina Marketplace
Kaiser
First Choice Health Network
Aetna
Cigna
ProviderOne or Other Apple Health Plan
No Insurance
Other
Insurance ID Number
Insurance Group Number
Insurance Subscriber
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Relationship to Patient
Picture of Insurance Card
Browse Files
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Cancel
of
I give consent for my child to receive:
All required and recommended childhood vaccines
COVID Vaccine
Annual Flu Vaccine
Only specific vaccines (please specify below)
Other Information
Signature
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