The Glen Rock Democratic Organization: Educator/Staff Intake

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Glen Rock Democratic Organization is happy to expand their Vaxes for Seniors Program to include Vaxes for Educators/Staff. Our programs are open to all, regardless of your voter registration status as we want to make sure everyone is safe and healthy :)

Qualifications:
Must live and/or work in Glen Rock and be
a Pre-K-to-12 educator or support staff or
be a Child care worker
Be willing to travel up to 35 minutes from Glen Rock for your appointment

If you do NOT fall within these categories of educator/staff visit https://www.glenrockdems.com/vaxes.html to see if you are eligible for our other program.

We are sorry, but right now we do not know how to book New York residents. So if you live in NY but work in Glen Rock please visit https://www.facebook.com/groups/891546924927251 to see how to book in NY.

Disclaimer: We will not share your personal info outside the team except to obtain your appointment.

Questions: GlenRockDems@gmail.com

Please confirm ALL of the following: *

Yes, I live in NJ and live or work in Glen Rock.

Yes, I can travel up to 35 minutes from Glen Rock.

Yes, I understand that appointments might be the next day.

Yes, I understand that my appointment will probably be on a weekday.

Yes, I understand that bookers will do their best to book early morning appointments or after school appointments but sometimes this is not possible.

Yes, I understand I will be responsible for rescheduling my appointment if needed.

Yes, I understand that bookers have no control over what vaccine I am given.

Yes, I understand that my personal information will be shared with our dedicated team of volunteers.

Required

Where do you work? *

GR High School

GR Middle School

Byrd School

Central School

Coleman School

Hamilton School

AoOL

Other:

What County do you live in? *

Bergen

Essex

Hudson

Middlesex

Morris

Pasasic

Sussex

Somerset

Union

Other:

First & Last Name (no initial and use whatever is on your driver's license) *

Your Email (that you check at night) *

Street Address (must match your driver's license) *

Town *

Zip *

Age *

Date of Birth *

YYYY

Cell Phone (201-444-4444 format) *

What date(s) in March or April must we exclude (3/24/2021 format):

Anything we should know?

If you book an appointment on your own, please alert us ASAP at GlenRockDems@gmail.com or 646-980-7452 so we can take you off our list.

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