2024 Vaccine Clinic Registration

2024 Vaccine Clinic Registration

Thank you for your interest in attending our vaccine clinics!
Use this form to register for a Bethel Community Life Center Vaccine Clinic.

This form is for one individual. Each person receiving a vaccine needs to have their own individual form. After you submit, there will be an option to fill out the form again if you need to register multiple people!

For minors, this form must be completed by a guardian who must also accompany them to the clinic. Please complete the form ABOUT the Minor.

The UPDATED COVID VACCINE is available at ALL listed clinics.

NOTE: VACCINES WILL NOW NEED TO BE COVERED BY INSURANCE.

Our Vaccine Clinics are held at:

Bethel AME Church of Ardmore

163 Sheldon Lane, Ardmore PA 19003

or

Ardmore Avenue Community Center

122 Ardmore Avenue, Ardmore PA 19003

Please bring your vaccination card (if you've already received a dose) and your health insurance card (if you have one).

Health Insurance is required. All vaccines need to be covered by insurance, the pharmacy will verify insurance the day before the clinic.

We do not reserve time slots, instead you will be selecting the clinic day you wish to attend and you can arrive anytime during the clinic operational hours. Vaccines/Boosters are administered in the order of your arrival to the Clinic.
Name of Person Receiving Vaccine*

First NameLast Name
Date of Birth

MonthDayYear
Date
Age*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Guardian Accompanying Minor*
Email*
We will subscribe this email to our news & updates email list and confirm your appointment.
Phone Number*
If patient is a minor, provide guardian's information.
If you are unable to use a staircase, we can have our Pharmacy team come to you. Please help us prepare for your access needs. Do you have any access requirements you would like us to be aware of?*

YesNo
Please describe below.*
Which clinic do you plan on attending?*

Wednesday, October 9 - 5:00PM to 7:00PM (122 Ardmore Ave)Monday, October 14 - 11:00AM to 1:00PM (122 Ardmore Ave)Wednesday, October 23 - 11:00AM to 1:00PM (122 Ardmore Ave)Tuesday, October 29 - 5:00PM to 7:00PM (122 Ardmore Ave)
Which vaccine(s) do you need? Check all that apply (Insurance is required)*

Covid-19FluFlu for 65+
Are you in need of a vaccine other than Covid and Flu? Choose which vaccines below and we will send your information over to the local Pharmacy: Skippack.

Prevnar20 (Pneumonia) for 65+ShinglesTDAPRSV for 60+
What Pfizer dose do you need?*

Pfizer Vaccine - 1st DoseUPDATED Pfizer Vaccine
What Covid-19 dose do you need?*

Moderna Vaccine - 1st DoseUPDATED Covid-19 Vaccine
Which pediatric vaccine(s) do you need? Check all that apply.*

Updated Pediatric Covid Vaccines are currently unavailable due to low supply. We will update this form should they come available but as of now, do not check this box. Instead continue to check back and when it becomes available, we will add it here for the specific dates.Pediatric Flu Shot
Do you have any comments or questions?
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