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Stockbridge-Munsee Community
COVID Vaccination Registration Request Form
Please complete a survey for each individual in the household who are
12 years
old or older
.
*
1.
Name of person requesting vaccine
(Required.)
Name
Address
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Email Address
Phone Number
*
2.
What is the date of birth for the person to be immunized? (mm/dd/yyyy)
(Required.)
*
3.
If registering for a minor, please list the name of the guardian that will be bringing the child?
(Required.)
*
4.
Have you received a vaccine for the COVID-19 Virus?
(Required.)
Yes
No
*
5.
Are you willing to receive a Vaccine for the COVID-19 Virus?
(Required.)
Yes
No
*
6.
Do you have a preference of which vaccine you receive?
(Required.)
Moderna
Pfizer (age 12 to under 18 must check this type)
Johnson & Johnson
No preference
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.
