居家疫苗接种服务登记表格
居家疫苗接种服务项目要帮助身体行动不便，病患，孤老无助，以及要照顾病人，老人，或幼儿等各种家庭工作或责任而不便出门的民众。民众可以通过此表申请费城公共卫生局的疫苗上门接种服务项目。请提供下面资料。 我们志工在一周内会与您联络做初步审核，然后将合格者的资料提供给相关部门来完成家访给您打疫苗。
您若懂英语和不需要翻译，您可以参考下面英文说明并直接跟卫生局登记。

除接种疫苗外，若有另外要求急难救助，也可以通过此表与本会说明您的状况以供评估。

请注意： 提交此表格即表示您同意东北费城公益协会与合作机构共享您的资料，以便安排家访事宜和任何更深入的帮助。本会主要协助不懂英语的民众找到社会资源和服务，但我们不能保证合作单位会接受您的申请和他们的安排与服务质量。

本会諮詢電話  215-839-8247‬；微信：2158396108
电子信箱Email: NEPCA.chinese@gmail.com
东北费城公益协会敬启  5/19/2021
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If you know English, you can register for this Homebound Vaccination Program directly with the Health Department by calling 215-685-5488 or use the link below:  https://bit.ly/homeboundvaccinephl
By submitting this form, you are consenting to having your information shared with vaccination providers and partners organization to schedule an appointment for a home visit and other assistances. NEPCA helps people who does not speak English seeking public benefits and services. We do not guarantee if you would get acceptance nor responsible for issues about  visitation arrangement and quality of services of the providers.
Other than vaccination, if you have additional hardship and wish to get help, you also can ask for help in this form.  
Northeast Philadelphia Chinese Association 5/19/2021
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名字 First Name: *
中间名字 Middle Name:
 姓 Last Name: *
地址 （ 门牌号码，街名）  Street Address: *
邮区  Zip code: *
电话号码 Phone Number: *
微信 WeChat:
Email 电子信箱 (如果有请提供）：
方便接电话时间  Best time to contact you:
需要英语翻译帮助 Need Help with English translation? *
懂语言 Language Speak: *
Obvezno
其它语言 Which Other Language:  
不便出门的理由 Reason for not be able to leave home: *
Obvezno
年龄组 Age range:   *
性别 Current Sex: *
请简单说明不便出门的理由并罗列出住在一起和希望能一同打疫苗的人。Please give more explanation and also list the members who live together that wish to be vaccinated together:  
说明任何疫苗药牌要求。Any specific request on the brand of COVID 19 vaccine：
哪里得到这个服务信息 Where do learn about this service： *
Obvezno
您居住或工作的费城区域 Which neighborhood do you Live or Work： *
Obvezno
价绍团体或个人, 例如： NEPCA, PCDC, AAU, 或 其它 Referal organization or individual:  
**急难救助**：除接种疫苗以外，如您有其他急难困难，并希望获得大众帮助，请在此说明您的状况以供评估。Other than vaccination, if you have additional hardship and wish to get help from the community, please state your request here for consideration.
如果您是为另一个无法帮助自己的人填写此表，请在此处提供您的姓名、电话，和与求助人的关系。If you are filling out this form for another person who cannot help his or herself, please provide helper's name, phone, and relationship here：  
公共卫生局原文通告 Original Notice from Health Dept:
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东北区其它中文服务通告 NEP Chinese Services Info:  
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This form is developed by the Northeast Philadelphia Chinese Association (NEPCA). Permission is granted to any non-profit agency to clone and customized this Google form for its own use to help the community. Any question, contact pearl.huynh@gmail.com.  Use the URL below to clone a copy:
https://docs.google.com/forms/d/1U_l15_KtSM76-D76Cm_CA8K1M8IGSnuqVm5CsqMw28Y/copy
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