RSVP Film Studios MODERNA vaccine sign-up Form

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This google form registration is intended for those interested in RSVP Film Studios’ Moderna mRNA covid 19 virus vaccine program. Early in 2021, we directly imported the Moderna vaccines to be given for free (gratis et amore) to our employees, and sold at cost (no profit) to industry friends while limited deliveries and supplies last.

As our program progressed and new FDA & DOH rules were degreed, we had to expand our google form requirements all together accordingly.

So as youth and booster shots are included in our program, please be informed that this “old” google form has been suspended. We now require everyone, new registrants, including former registrants, to register again at the new google form:

https://forms.gle/ABWtxU9dFrZvXXNZ9

As usual, our commitment and liabilities are limited, not contractual, ala your employee, best effort, dependent on international delivery, while supplies last, non refundable, full or partial refund solely at our choice, subject to (DOH, FDA, ICTSI, Zuellig Pharma & Solaire) rules, no direct or indirect liability, other limitations and waivers apply, in perpetuity, etc.

Thank you for doing your part to reach and exceed herd immunity.

Oli & Rafa Laperal

RSVP Film Studios

Email *

Confirm Email (must be the same as above. must be unique to ONLY ONE person. ) *

Priority Group *

01_A1: Health Care Workers

02_A2: Senior Citizen

03_A3: Adult with Comorbidity

04_A4: Frontline Personnel in Essential Sector / Media Workers

05_A5: Poor Population

06_B1: Teachers and Social Workers

07_B2: Other Government Workers

08_B3: Other Essential Workers

09_B4: Socio-demographic Groups

10_B5: Overseas Filipino Workers

11_B6: Other Remaining Work Force

12_C: Rest of the Population

Sub-Priority

Last Name *

First Name *

Middle Name *

Suffix

Choose size and number per color

III

N/A

Clear selection

Mobile Number *

Confirm Mobile Number (must be the same as above. must be unique to ONLY ONE person. ) *

Region *

Province *

Municipality / City *

Barangay *

Number and Street *

Sex *

Male

Female

Birthdate *

YYYY

Age (2 numbers ONLY, no letters) *

Occupation *

Any known allergies, Medical Conditions, or Comorbidities? *

Organization / Company Name / Club Name *

Employee Number / Any gov’t ID number / Any unique number *

COVID-19 Vaccine History details *

None

Have registered with Barangay

With barangay schedule for 1st vaccine dose

1st vaccine dose done

With barangay schedule for 2nd vaccine dose

2nd vaccine dose done

Other:

If vaccinated already please indicate vaccine brand, date of vaccination, and barangay

If you register twice, the system will automatically remove your earlier registration

By clicking the box below, you fully agree to the following *

Data Privacy Consent Form / Waiver of Liabilities / All rules and regulations / Non-disclosure agreement / Best effort basis / Subject to availability and change

Required

Note

The MODERNA vaccines are FREE to regular employees and RSVP freelancers*.
However, this is also open to everyone at bare cost, subject to availability.
If you wish to reserve, register and purchase more vaccines for family and friends, depending on availability and subject to conditions, the cost will be 1,300 Php per dose plus 350 php for health providers fee for a total of 3,300 php for two (2) doses.
Vaccine availability : Q3 2021, Q4 2021 , Q1 2022, OR until supplies last*

Data Privacy Consent Form

I authorize and give my consent to RSVP Film Studios to collect, store, transmit, use, distribute, disclose, share, retain, dispose, destroy, and process the required information which may be considered personal information and/or sensitive personal information under the provisions of the Data Privacy Act of 2012 and its Implementing Rules and Regulations that I shall submit along with this form. I understand that the personal information and/or sensitive personal information that I am freely submitting shall be collected, recorded, processed, stored and utilized as necessary. By filling out the form and submitting the required personal information and/or sensitive personal information through this platform, I am freely giving my specific and informed consent to its use, retention, and disposition in accordance with the Data Privacy Act of 2012.

A copy of your responses will be emailed to the address you provided.

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