COVID Vaccination Registration Request Form

Please complete a survey for each individual in the household who are 18 years old or older.

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* 1. Contact Information

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* 2. Have you received a vaccine for the COVID-19 Virus?

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* 3. Are you willing to receive a Vaccine for the COVID-19 Virus?

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* 4. What is your date of birth? (mm/dd/yyyy)

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* 5. Are you a Stockbridge-Munsee Tribal Member?

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* 6. Are you a partner of a Stockbridge-Munsee Tribal Member?

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* 7. Are you a descendant of the Stockbridge-Munsee Tribal?

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* 8. Are you a household/community member of the Stockbridge-Munsee Community?

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* 9. If you answered yes to question #8, is the community member age 65 or older?

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* 10. Are you an employee of the Stockbridge-Munsee Community or the North Star Mohican Casino Resort?

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* 11. Are you a faculty member at the Bowler, Gresham or Wittenberg School Districts?

You have now completed Step 1 of the COVID-19 Vaccine Registration. Please be patient. We will contact you to complete the registration process as vaccines become available. Thank you.

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