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Vaccine Sign-Up at Temple of Deliverance Ministries Int'l Site
See Vaccine Eligibility:
http://publichealth.lacounty.gov/acd/ncorona2019/covidvaccinedistribution/
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* Indicates required question
Email
*
Your email
Have you previously received a COVID-19 vaccine?
*
Yes
No
Please check all that apply:
*
Resident of Long-Term Care Facilities
Persons of 65 year and older
Have any underlying health condition or disability which increases your risk of severe COVID-19
Individuals employed in: healthcare, emergency services, education and childcare, food & agriculture, janitorial, custodial and maintenance services, transportation and logistics. (Please specify in "Other".)
Other:
Required
Have you ever had a severe allergic reaction (e.g, anaphylaxis) to another vaccine (not including Pfizer-BioNTeach Vaccine) or any other injectable medication?
*
Yes
No
First Name
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Your answer
Last Name
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Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Sex
*
Female
Male
Prefer not to say
Other:
Race/ Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Required
Phone Number
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
A copy of your responses will be emailed to the address you provided.
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