您好！如果您想 Epicenter 帮您登记日期打新冠疫苗，请填写下面的表。我们会尽力为您
提供住宿，但请知道我们是个义工组，所以我们不可以担保会找到一个日期给您。请注意
，我们可能需要几个小时或者几天才能找到一个。另外，预约时间可能是在深夜或远离家
中或地铁站。

Hello! Please fill out the form below if you want Epicenter-NYC to help you request a vaccine appointment. We will try our best to accommodate you but please know this is a volunteer effort and we have nothing to do with the administration of vaccines. We are just trying to help folks. Please be aware that it can take us several hours, even days, to snag one. Also appointment times may be in the middle of the night or in locations far from your home or subway lines.

遞交之前請閱讀：本人請求Epicenter集團及其義工幫助我在紐約州進行接種疫苗預約登
記，包括下列步驟：1. 代表本人填寫個人資料，例如本人的姓名、出生日期以及聯絡資
料；2. 代表本人確認本人符合接種疫苗的資格。本人明白本人向接種疫苗機構如實提供
資料；本人對提供資料的真實性承擔法律責任；本人明白本人需提供個人身份證明以及符
合接種疫苗的資格證明。本人明白及同意Epicenter集團及其義工沒有責任去驗證本人為
接種疫苗所提供的資料，同時為本人所提供的有關資料負全部的法律責任。

PLEASE READ BEFORE SUBMISSION: I have asked the Epicenter group and their volunteers to assist me with registering for a COVID vaccine appointment in New York State, including by taking the following steps on my behalf: a) collecting and submitting the personal information I have provided, such as my name, date of birth, and contact information; b) submitting my confirmation that I am eligible for the vaccine. I understand that I am providing this information to vaccine providers under penalty of perjury; that I am fully responsible for its accuracy and truthfulness; and that I will be expected to provide proof of identification and eligibility at my vaccination appointment. I understand and agree that the Epicenter volunteers are not responsible for verifying the accuracy of the information I have provided or my eligibility for the vaccine, and that I am solely responsible for what they submit on my behalf.

订阅我们的新闻通讯以获取更多资讯和更新：(Subscribe to our newsletter for more
information and updates here: https://epicenter-nyc.com/subscribe/)

如果您有任何疑问或问题，请发电邮给 hello@epicenter-nyc.com 。
If you have any questions, issues, or concerns please contact us at hello@epicenter-nyc.com.

您的注册/确认会通过电子邮件发送。
Your registration screenshot/confirmation will be
sent by email.

多多保重！
Stay safe!

在下面输入电邮地址