Vaccine Assistance and/or Eligibility Letter Request: parent/caregiver of a person with Down syndrome / Solicitud de carta de elegibilidad para la vacuna: cuidador de una persona con síndrome de Down

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Per the Department of Health, caregivers of people with Down syndrome, whether they are paid or unpaid, are eligible for vaccine now as home health care workers (phase 1a, priority 3). DSAMN will provide a letter for any person who acts as a caregiver for a person with Down syndrome who lives in their same household.

Según el Departamento de Salud, los cuidadores de personas con síndrome de Down, ya sean remunerados o no, son elegibles para la vacuna ahora como trabajadores de atención médica domiciliaria (fase 1a, prioridad 3). DSAMN proporcionará una carta para cualquier persona que actúe como cuidador de una persona con síndrome de Down que viva en su mismo hogar.

Email *

Untitled Title

Your First Name / Su nombre de pila *

Your Last Name / Su apellido *

Your Phone Number / Su número de teléfono *

Street Address / Dirección de la calle *

City / Ciudad *

State / Estado *

Zip / Código postal *

Name of Household Member with Down syndrome / Nombre del miembro del hogar con síndrome de Down *

Birthdate of Household Member with Down syndrome / Fecha de nacimiento del miembro del hogar con síndrome de Down *

Do you need assistance booking an appointment? *

I already have an appointment, I just need a letter.

Help! I need help finding and appointment and I need a letter.

Other:

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Down Syndrome Association of Minnesota. Report Abuse

Forms