LA County COVID-19 Vaccination Reservation

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If you live in any of the 7 following cities--Maywood, Bell, Cudahy, South Gate, Huntington Park, Commerce, Lynwood-- you are eligible to receive a single dose COVID-19 Vaccination as provided by the Maywood City Council. Further eligibility requirements include being at least 18 years of age and meeting at least one of the following:
1) Healthcare workers
2) Residents or workers of skilled nursing facilities or other long-term care facilities
3) 65 and older
4) Food and agricultural workers
5) Emergency services workers
6) Education and childcare workers
7) Janitorial/Custodial and maintenance services in public spaces
8) People between 18-64 years old with disabilities, underlying health conditions
9) People who live or work in prisons, homeless shelters, other residential facilities
10) Transit and airline workers
11) Individuals age 50-64 years old

The vaccination site for all Southeast LA residents will take place on Wednesday, April 7, 2021. There will be an additional vaccination site on Thursday, April 8, 2021 for residents of Maywood exclusively. In order to receive your vaccination, you must fill out an RSVP Google Form in order to secure your spot at the vaccination site. After completing this form with your information, you will receive a follow-up email confirming your registration. This email will also provide more details and instructions about the vaccination sites. For more information, please send questions to vaccine@ichealthinitiative.org.

Email *

First Name (Nombre) *

Last Name (Apellido) *

Gender (Género) *

Female (Mujer)

Male (Hombre)

Transgender (Transgénero)

Gender non-conforming / Genderqueer (Género no conforme / Genderqueer)

Decline to answer ( Negarse a contestar)

Other:

Race/Ethnicity (Su Raza / Etnia) *

American Indian / Native American or Alaska Native

Arab-American

Asian / Asian American

Black/ African American / Afro Caribbean / African

Latinx / Hispanic

Native Hawaiian or Pacific Islander

White/ Caucasian

Multi- Racial / Multi Ethnic

Decline to state

Other:

Language Preference (Preferencia de Idioma) *

English

Spanish

Other:

Phone Number (número de teléfono) (ex. XXX-XXX-XXXX) *

Birth Date (Fecha de Nacimiento) [Please note you must be at least 18 years of age in order to be eligible for vaccination.] *

YYYY

Address (Direccion) *

City (Ciudad) *

5 Digit Zip Code (Codigo Postal) *

Please select which of these groups you identify with. [Please note you must qualify for at least one of these groups in order to be eligible for vaccination.] *

I am a healthcare worker (Trabajadores de la salud)

I am a resident or worker of skilled nursing facilities or other long-term care facilities (Residentes o trabajadores de centros de enfermería especializada u otros centros de atención a largo plazo)

My age is at least 65 years old (65 años o más)

I am a food and agricultural worker (Trabajadores agrícolas y alimentarios)

I am an emergency services worker (Trabajadoras de servicios de emergencia)

I am an education and childcare worker (Trabajadores de la educación y el cuidado infantil)

I work in janitorial/custodial and maintenance services in public spaces (Servicios de limpieza / Conserjería)

I am between 18-64 years old with disabilities and/or underlying health conditions (Persona entre las edades 18-64 anos con problemas de salud y discapacidades)

I live and/or work in prisons, homeless shelters, other residential facilities (Personas que viven o trabajan en cárceles, refugios para personas sin hogar, otros espacios residenciales)

I am a transit and/or airline worker (Trabajadores deTránsito y Aerolíneas)

My age is between 50-64 years old (Personas de la edad de 50 a 64)

Southeast LA Residents: Which time slot are you able to attend on the vaccination site date- Wednesday, April 7, 2021? (Miércoles, 7 de Abril de 2021) *

Maywood Residents only: Which time slot are you able to attend on the vaccination site date- Thursday, April 8, 2021? (Jueves, 8 de Abril de 2021) *

I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that providing false information may disqualify my registration. *

By checking this box, you are electronically signing to agree with the statement above.

Send me a copy of my responses.

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