COVID-19 Vaccination Inquiry Form

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La Parroquia de San Patricio está trabajando con una Farmacia de la ciudad Racine para traer una clínica de vacunación a San Patricio (Vacuna contra el Covid). Esta campaña de vacunación es para todas las personas mayores de 12 años . La fecha se fijó para el 10 de agosto para la primera vacuna. La segunda vacuna es el 21 de agosto.
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St. Patrick's Parish is working with a Racine City Pharmacy to bring a vaccination clinic to St. Patrick's (Covid Vaccine). This vaccination campaign is for all people over 12 years. Please fill out this inquiry form to be contacted. The date has been set for August 10 for the First Shot. The Second Shot is August 30

Email *

LAST NAME / APELLIDO *

FIRST NAME / PRIMER NOMBRE *

DATE OF BIRTH / FECHA DE NACIMIENTO *

YYYY

IF THE PERSON TO BE VACCINATED IF UNDER 18 YEARS OF AGE, THEY MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN / SI LA PERSONA A VACUNAR ES MENOR DE 18 AÑOS, DEBE ESTAR ACOMPAÑADA DE UN PADRE *

I UNDERSTAND / ENTIENDO

PHONE NUMBER / NUM. DE TELEFONO *

Do you prefer to be contact via / ¿Prefieres ser contactado a través de: *

Phone / Telefono

Email/ Correo Eletronico

A copy of your responses will be emailed to the address you provided.

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