Nelson County Response Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Join us for the Coming Together Again Safely Cookout and Vaccination clinic on Saturday, August 7th from 5-7 pm at Central Baptist Church in Lowesville, Virginia.

This is a free public event. We will have hot dogs, hamburgers, veggie burgers, and raffle really awesome prizes for registering and/or getting your COVID-19 vaccine.

REGISTER FOR THE RAFFLE BY PROVIDING YOUR INFORMATION BELOW!

Name *

I am eligible to enter the raffle because: *

I have already received my vaccine.

I have an appointment to receive my vaccine.

I will receive my vaccine at the mobile clinic during the cookout.

Required

Home Address *

Phone Number *

My preferred method of communication is:

Telephone

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Four Oxen. Report Abuse

Forms