COVID Vaccination Clinic for the DHS Community

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March 31 at Dekalb Pediatric Center at 350 Winn Way, Decatur, GA 30030
You will be contacted with an appointment time between 11am -2pm by email. If you do not have an email, you will be contacted by phone.
Please bring your card (Medicaid, Medicare, Private Insurance). if you have insurance. You do not need to have insurance to vaccinated.
16 and 17 year olds must have a guardian or family member (older than 21y present)
Each person wanting to be vaccinated must fill out a registration form. Staff and family members of students are also welcome. There are limited spots but we will create a waitlist if needed.
DO NOT SIGN UP THE SAME INDIVIDUAL MORE THAN ONCE.

Email *

Last Name *

First Name *

Address *

City *

Zipcode *

County *

Date of Birth *

YYYY

Ethnicity *

Hispanic or Latino

Non- Hispanic /Non Latino

Prefer not to anwer

Race *

American Indian and Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Prefer not to answer

Insurance (there will be no cost or cost share, however your insurance will be billed for an administration fee. If you do not have insurance, please write "no insurance") *

Insurance ID Number *

Policy Holder ( First and last name) *

Policy Holder (Date of Birth) *

YYYY

Send me a copy of my responses.

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