Whose House? GOD's House: Vaccine Pre-Screening for Parishioners

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The following information will be utilized as a faith-based community effort to provide additional vaccination sites for members of our church community. Please complete ONE form for EACH person desiring to get vaccinated. We will be in touch with you regularly through text messages and emails.

Email *

Your Last Name *

Your First Name *

Contact Email Address *

Contact Phone Number (where you can receive text message updates) *

Your Street Address *

City

Zip Code *

Name of Church Affiliation *

City where your church is located? *

Are you signing up for the COVID vaccine through this site? *

Yes

According to State of Maryland guidelines, which category(s) do you fit into? Check all that apply to you. *

65 or older

Health Care worker

Resident or staff at long-term care facilities

First Responder

Higher risk due to pre-existing illness (diabetes, cancer, sickle cell, etc.)

Public or Charter School Employee

Daycare Employee

Lives with someone who is high risk

General Population

Clergy

Other:

Required

Do you need transportation to or from a vaccination site? *

Yes

If you are a healthcare professional, select all that apply.

Physician

Registered Nurse

Nurse Practitioner

Physician Assistant

Pharmacist

None of the above apply

Other:

Volunteers please check all that apply: *

I can provide transportation using my own vehicle for those in need.

I can volunteer at one of the designated sites to assist with registration.

I can assist with site set-up.

I can independently maneuver around the internet to connect on Zoom and assist others with filling out forms.

Not volunteering

Required

Send me a copy of my responses.

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