AnarchoVax Vaccination Application

Wooden Shoe Books & Records is partnering with Health on South Rx to provide free COVID vaccines for uninsured and under-insured community members. For this program, you are considered under-insured if you have health insurance that does not allow you to access or afford vaccination.

Vaccines are safe and effective medical technology that keep us healthy and protect our neighbors from transmissible illnesses. Not everyone can take every vaccine, so if you are able to receive one please strongly consider it. The Wooden Shoe is trying to expand access. Please fill out the form below if this interests you.

As funds are limited, we are only covering COVID vaccination.

First Name*

Are you uninsured or under-insured?*

YesNo

Are you seeking a COVID vaccine or booster?*

YesNo

Do you have any allergies to medications?*

YesNoUnsure

Preferred Contact Method (Select one to add the contact information)*

EmailPhoneOther

Email

Confirmation EmailIf you selected "Email" as your preferred contact method, please provide your email address here.

Phone Number

If you selected "Phone" as your preferred contact method, please provide a valid phone number here.

Thank you for submitting! We will not be able to accept every applicant, but depending on interest, we may extend the partnership and expand the access program. If you are not selected, we may contact you at a later date if the program is continued.

If you are selected, we will be in contact with next steps within one (1) week of application receipt. Please be sure to check your spam folders/filters.