BASD CRCHD Vaccination Sign-up Form

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We need to collect the names and contact information to get a clear count of how many people will use the BASD-sponsored vaccination opportunity.

Deadline for bus drivers and food service: *WEDNESDAY, MARCH 5, 2021 at 12 noon*

LAST name

FIRST name

Date of Birth

YYYY

Primary Phone Number

Secondary Phone Number

Email address

Available to return - The 2nd dose date will be Wednesday, March 31. Please check this box to verify that you understand this requirement and you are available to return for the 2nd dose. *

Yes, I will return for the 2nd dose of COVID-19 vaccine on March 31

No, I will not return for the 2nd dose

I am an Aramark employee:

Yes

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