COVID-19 Vaccination Pre-Registration

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FREE TO PRE-REGISTER FOR PFIZER VACCINE
*By pre-registering your name will be added to the list*

Pfizer Vaccine is Available for Anyone Ages 12+
Date: July 17th, 2021
Time: 2:00PM - 3:30PM
Location: 177 Hanover Street, Providence, RI 02907

Community Outreach Specialist Contact Information
Aliyah Phommarath (ENGLISH/LAOTIAN) csri.aliyah@gmail.com
Sokunthea Tip (ENGLISH/KHMER) csri.sokunthea@gmail.com

COVID-19 Vaccine Pop Up Clinic run by non-profit organization Cambodian Society of Rhode Island (CSRI) in partnership with Rhode Island Department of Health (RIDOH)

Full Name *

Date of Birth *

YYYY

Age *

Address (Street, City, and Zip code) *

Phone Number *

Email *

Any known medical history, concerns, and/or allergies? *

Are you pregnant or planning to conceive? *

Yes, I am pregnant

Have plans on conceiving a child

How do you prefer to be contacted? *

Call

Text

Required

Preferred Language *

English

Khmer (Cambodian)

Español (Spanish)

Other:

Best Time To Contact *

Morning

Noon

Afternoon

Evening

Other

Required

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