REQUEST FOR HELP TO FIND AN APPOINTMENT For The COVID-19 VACCINE.Please note, this service is prioritize to our seniors over 62 first.

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* required

What county do you live in? *

Camden

Gloucester

Other:

First Name *

Last Name *

Gender *

Female

Male

Age *

Date of birth *

YYYY

Email( If you do not have an email address simply type N/A)

Home Address Line 1 *

City *

State *

Zip Code *

Phone number - You will get a text confirmation when you are schedule for an appointment.Do not use the same phone number as your spouse. Please bring your ID and medical insurance cards to CVS. *

Are you willing to travel 30-45 mins from your zip code if a local CVS store is not available? *

Yes

Are you in need of an additional appointment for a spouse? *IMPORTANT IF THE ANSWER IS YES THEN YOU NEED TO FILL OUT THIS REQUEST FORM TWICE. Your spouse needs their own phone number. Do not use the same phone number as your spouse. *

Yes

Is there anything else you like for us to know? *

Who referred you to this service? No name, no service. *

Are you over 65 and have the Red, White, and Blue Medicare Card? *

Yes

Are you over 65 and have the Medicaid card? (etc. NJ FamilyCare card) *

Yes

Other Medical ID cards besides Medicare or Medicaid *

Yes

I understand that if one of the volunteers books me an appointment and the time/date/location/etc no longer works for me then I am responsible for cancelling the appointment on my own via the text or email confirmation. Our volunteers are unable to handle the additional work of cancelling appointments. I also understand that if a volunteer tries to contact me several times and I do not respond within 48 hours I will need to reapply for assistance as I will be removed from the queue. * *

Yes

Required

Want to say thank you - please pay it forward by doing something nice to someone else! Stay safe and wear your mask! *

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