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.

Question Title

* 1. Name of person requesting vaccine

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. What is the date of birth for the person to be immunized? (mm/dd/yyyy)

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* 3. If registering for a minor, please list the name of the guardian that will be bringing the child?

Question Title

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

Yes

Question Title

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

Yes

Question Title

* 6. Do you have a preference of which vaccine you receive?

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.