February 5, 2021 COVID-19 Testing Event # 4:
Registration Page

REGISTRATION FOR VMRC COVID-19 TESTING EVENT

Valley Mountain Regional Center COVID-19 Testing Event in Stockton on Friday February 5, 2021 from 8 am to 12 pm in the VMRC Parking Lot (702 N. Aurora Street, Stockton).

Question Title

* 1. Name

First Name

Last Name

Address

City

State

ZIP Code

Email Address

Phone Number

Question Title

* 2. Race (please format as: Afro-American, Asian, Native American, Native Hawaiian or Other Pacific Islander, other Race, or White)

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* 3. Ethnicity Group (please format as: Yes Hispanic, Not Hispanic or Latino, or Unknown)

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* 4. Date of Birth

Birth Date (Month, Day, Year)

Date

Question Title

* 5. Gender

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* 6. Reason for Testing

for exposure to COVID-19

for preadmission or pre-surgical testing for COVID-19

for return to school testing or school admission (COVID-19)

for return to work testing (COVID-19)

for suspected COVID-19

Use when COVID-19 has been confirmed

Encounter for asymptomatic screening for other viral diseases

February 5, 2021 COVID-19 Testing Event # 4:Registration Page

REGISTRATION FOR VMRC COVID-19 TESTING EVENT

Question Title

* 1. Name

Question Title

* 2. Race (please format as: Afro-American, Asian, Native American, Native Hawaiian or Other Pacific Islander, other Race, or White)

Question Title

* 3. Ethnicity Group (please format as: Yes Hispanic, Not Hispanic or Latino, or Unknown)

Question Title

* 4. Date of Birth

Question Title

* 5. Gender

Question Title

* 6. Reason for Testing

Question Title

* 7. What time should we expect you?

February 5, 2021 COVID-19 Testing Event # 4:
Registration Page