Flu Vaccine Registration Form

FREE Flu Shots - Registration Form
Vaccination Clinic - Saturday, November 8th | 11:00 am - 2:00 pm

Serving with Grace, Inc. is exicted to partner with Walgreens and Sunset Presbyterian Church to offer free flu vaccinations to our community.

Guests must sign up (adults and children) in order to be considered. No insurance is required and participants must show ID.

We are giving away gift cards to the first 50 participants (adults only) after completing their vaccination.

Sign up now! You must register each person that requires vaccination (including children). If you are registering children, please submit this form again.

Name of person being vaccinated*

First NameLast Name

Is the person who is registering an adult or a child?*

AdultMinor/Child

If the person you are registering is a minor, please enter the parent or guardian's name below as well.

Parent First NameParent Last Name

Phone Number*

If registering a child, use parent's phone number

Email*

example@example.com - If registering a child, use parent's email

Zip Code*

City*

Date of Birth of Person Registering*

Date

Gender*

Age*

Note: Vaccinations are free for ages 3-64.

Note:

Flu vaccinations will be administered by trained professionals and pharmacists from Walgreens.
You must submit a separate registration form for each person who requires a vaccine, including children.
Vaccinations are free, but will only be available for ages 3-64.
Insurance is not required.
Participants must show their ID that provides proof of identification and age.
Gift cards will be distributed to the first 50 attendees (adults over 18 only) after completing your vaccination.