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Token of Hope Inc. New York Pre-Application For Vaccines In the Harlem Community

Token of Hope Inc. New York is working hard to connect the Harlem community to much needed resources and help. In partnership with the Manhattan Borough President Office, Token of Hope Inc. is collecting names of residents in the Harlem community in need of the vaccine.  This information will be provided directly to the Manhattan Borough President's staff for expedition and attention. Please complete this survey as soon as possible to ensure that you receive service as the vaccine is available.

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* 1. Please provide your first and last name.

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* 2. Street Address and Apartment Number

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* 3. City

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* 4. State

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* 5. Zip Code

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* 6. Email Address

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* 7. Phone Number

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* 8. Please select your eligibility for the Vaccine.

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* 9. Do you have proof of your eligibility? You will be asked to bring a copy of your work ID, pay stub or letter from your employer verifying your eligibility.

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* 10. Do you have certification of your medical condition? If you are eligible for vaccination due to a medical condition, please bring a doctor’s note or complete the Certification of Eligibility to Medical Condition Form.

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