Union United Methodist Church COVID-19 Vaccine Pre-registration

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Union United Methodist Church at 201 Railroad Ave., St. Michaels, MD 21663
DATE: Saturday, May 8 and June 5, 2021 (Note: This is the Moderna 2-shot vaccine)
TIME: 10 am – 2 pm
You will receive a follow-up call to verify information and to schedule an appointment prior to the clinic date.

First Name *

Last Name *

Gender *

Male

Female

Non-Binary

Prefer not to say

Other

Chose Not to Disclose

Date of Birth *

YYYY

Mailing Address (including City, State and ZIP) *

County *

Home Phone # (no dashes/spaces) *

Mobile Phone # (no dashes/spaces) *

Email Address

Ethnicity *

Not of Hispanic Latino or Spanish Origin

Cuban

Hispanic Latino or Spanish Origin

Mexican Mexican American or Chicano

None-Hispanic

Puerto Rican

Other

Prefer Not to Say

Race *

American Indian or Native Alaskan

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Multiracial

White

Other

Prefer Not to Say

Previously received COVID Vax? *

Yes

Previous reaction to COVID Vax? *

Yes

Tested positive to COVID in past 10 days? *

Yes

Received Monoclonal Antibodies/Plasma for COVID-19? *

Yes

History of an Anaphylactic reaction to anything? *

Yes

Bleeding disorder or on Blood Thinners? *

Yes

Taking immunosuppressive medication or weakened immune system? *

Yes

Do you have a fever or are sick? *

Yes

Pregnant or Breastfeeding? *

Yes

Received any other VAX in the past 14 days? *

Yes

Will need additional assistance after VAX? *

Yes

Will you need transportation to the vaccination clinic? *

Yes

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