VACCINE FOR COVID-19 12 YEARS AND UP         WĀ IN BOBRAE NAÑINMEJ IN COVID-19 12 IO LOÑ LOK
Please fill out the below form so that we may set appointment for you and/or your child to get their vaccine. If you have any questions, please contact myoc.contact@gmail.com or text 714-583-0123. Please have with you upon arrival, a valid ID and insurance card. Vaccines are FREE OF COST and insurance is NOT a requirement and YOU WILL NOT BE TURNED AWAY if you do not have insurance.

Jouj kanne form ñan karōk am ak ro nejim ien ñan bōk wā in nañinmej in. Ñan melele ko rellab lok kebaak myoc.contact@gmail.com ñe ejjab, text tok ñan 714-583-0123. Jouj bojak kin juon kein kamool ak ID. Wā in bobrae nañimej in COVID-19 ej ñan AOLEB kin EJJELOK wonāān. EJJELOK enaj JOĻ jen an bōk wā in nañinmej in, JEKDRON ÑE REJ JAB MAROÑ KOLLA ONĀĀN ro rej lorlorjake jerbal in. AOLEB ARMIJ remaroñ bōk wā in, jekdron ia rej jebar jene.

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First Name/Etam *
Last Name/Etan Bamle eo am *
Phone number/Teiñwa *
Email/Email *
Street Address/Namba im Weto *
City/Bukon *
State/Aelōñ *
Date of Birth/Io in lotak *
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Age/Io ne am
Gender/Kadkadum
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Day of Appointment/Raan in etal eo am *
MM
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DD
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YYYY
Time Preference/Ien Eo *
Vaccine/Wā in bobrae *
Is this your first or second shot?/Wā eo kein kajuon in am ke kein karuo? *
Have you had COVID-19 before?/ Emōj ke am kar bōk nañinmej in COVID-19 moktalok?
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Do you need transportation/Kwōj aikuj ke ial lok ñan jikin wā? *
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