10/8 Billerica Vaccine Clinic Sign Up

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Complete the below information to sign up for the vaccine clinic on Friday, October 8th from 4-6pm at the Billerica Council on Aging, 25 Concord Road. If this is a second or third shot, be sure to bring your vaccine card.

View this link for information on third shot eligibility: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html

Please bring insurance information if you have it. If you are under 18, please bring a signed consent form, which can be found here: http://tiny.cc/2x6juz

First Name *

Last Name *

Date of Birth *

YYYY

Gender

Male

Female

Unknown

Other:

Clear selection

Race

Native American

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other Race

Unknown

Clear selection

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Unknown

Clear selection

Address *

Town *

Zip *

Phone *

Email *

What number shot will this be for you? *

First

Second

Third

What time do you plan to attend? *

4-5pm

5-6pm

Not sure

Submit

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