Al Ihsan Islamic Center COVID-19 Vaccination Site
Assalamu Alaykum!

We are excited to announce that we will be collaborating with MAS MN and the Minnesota Department of Health (MDH) to administer COVID-19 vaccines to everyone!


We will be offering the Johnson & Johnson vaccine, which is a one-dose shot. We have 300 doses available on this day. You MUST be at least 18 years or older to get vaccinated.

Registration is required and vaccines will be given on a first come, first served basis.

Date: Thursday April 8, 2021
Time: 1:30 pm - 3:30 pm
Location: Al Ihsan Islamic Center, 955 Minnehaha Ave. W Saint Paul, MN 55104

** When you register, PLEASE be sure you can make it to the time you select.**


- If you have any questions about the vaccine, please email: alihsanic955@gmail.com OR call 612-271-2471.

- If you would like to receive help with filling out the registration form, please call 651-399-0926.

- For more information about the COVID-19 vaccine, please visit the Minnesota Department of Health's COVID-19 Website here: https://www.health.state.mn.us/diseases/coronavirus/vaccine/basics.html#safe

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Email *
Part 1: Demographic Information
First Name *
Last Name *
Email address *
Home address (house number and street) *
City *
Zip code *
State *
Cell phone number *
What is your race? *
Gender *
What is your ethnicity? *
Date of Birth *
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Part 2: Appointment Schedule
Vaccinations are only being offered on April 8, 2021 between 1:30 - 3:30. You may only select ONE appointment slot. Please DO NOT be late or you may risk losing your appointment.
Vaccinations are only being offered on April 8, 2021 between 1:30 - 3:30. Please select ONE appointment slot. Please DO NOT be late or you may risk losing your appointment. *
Part 3: Consent
This vaccine is authorized by the Federal Drug Administration (FDA) under an Emergency Use Authorization (EUA). It is provided at no charge. Reported side effects include, but are not limited to: injection site soreness, fatigue, headache, muscle pain, and joint pain. * *
Required
I give consent to A&E PHARMACY and its staff to be vaccinated with the COVID vaccine. * *
Required
I agree to release from liability and agree not to sue Al Ihsan Islamic Center, its employees, affiliates and agents, for any damages, loss, injury, or death arising from the participation of each participant listed on this form throughout the duration of this vaccine clinic. *
Required
We have enough doses for everyone and we look forward to serving you. Please only register here if you are SURE. If you are getting the vaccine somewhere else, please register at the other location. It causes problems for our community if you register then cancel or just don't show up. Thank you. *
Required
The vaccine is not to be wasted. If for any reason I am unable to come to my vaccination appointment, I agree to call or send an email cancelling my appointment so someone else can benefit from it. *
Required
I understand that Al Ihsan Islamic Center may have to cancel my appointment for any unforeseen reason. * *
Required
Please provide information about your health insurance provider and your policy/member number.    (The vaccine is free, but the pharmacy will try to charge your insurance company the cost of administering the vaccine.) IF YOU DO NOT HAVE INSURANCE, OR PREFER NOT TO PROVIDE IT, SIMPLY WRITE "NONE". *
Part 4: Health Screening Questions
If your response to ANY of the 7 questions below is YES, you may not receive the vaccine from this vaccination site. Please consult your healthcare provider.
Are you sick today (fever of 100.5 or higher)? (If yes, you may not receive the vaccine at this time). *
Have you received any vaccines in the past 14 days and/or received any other COVID-19 vaccine at any time? (If yes, you may not receive the vaccine at this time). *
Do you have a current positive COVID-19 infection?  (If yes, you may not receive the vaccine at this time) *
Have you previously been ill with COVID-19 AND received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment in the last 90 days? (If yes, you may not receive the vaccine at this time). *
Have you been exposed to a known COVID-19 positive individual in the last 14 days?  (If yes, you may not receive the vaccine at this time). *
Have you ever had anaphylaxis (allergic reaction) or had other severe symptoms after receiving another vaccination or an injectable medication? (If yes, you may not receive the vaccine at this time). *
Do you have a history of an anaphylactic reaction to anything other than a vaccine or injectable medication (such as a reaction to food, insect stings, or oral medication)? *
Are you immunocompromised, or is currently on immunosuppressive therapy? *
Are you currently pregnant? *
Are you currently breastfeeding? *
This is the end of the registration form. Reminder: please be on time for your appointment. If for any reason you decide to cancel, please email alihsanic955@gmail.com or call 651-399-0926 24 hours in advance.
A copy of your responses will be emailed to the address you provided.
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