Vaccine Appointment Assistance

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Garfield Neighbors is creating a team of volunteers who will be registering Garfield residents who are eligible for the COVID-19 vaccine and are 55+. If you are a Garfield resident, eligible for the COVID-19 vaccine, 55+ years old, and need assistance registering for an appointment, please fill out this form.

Appointments are created by a team of volunteers and we cannot guarantee an appointment. DO NOT solely rely on Garfield Neighbors for your vaccination appointment.

All information submitted must be accurate and as it is on your identification, as this information will be used to create appointments.

If you have any questions, please email GarfieldNeighborNetwork@Gmail.com

Please confirm the following: *

I am a current resident of Garfield, New Jersey.

I am eligible for the vaccine (55+).

I understand my appointments may be at an undesirable time (i.e., the next morning).

I understand that my appointment will probably be on a weekday but might be on a weekend.

I understand I will be responsible for rescheduling my appointment if needed.

I understand that volunteers have no control over what vaccine I am given.

I understand that my personal information will be shared with our dedicated team of volunteers.

Required

Who is filling out this form?

Self

Other (i.e., grandson)

Clear selection

Name of person receiving vaccine (first and last as it appears on ID) *

Address (as it appears on ID; MUST be a Garfield resident) *

Email (either of the person or point of contact; N/A if no email) *

Primary Phone Number *

Secondary Phone Number/relationship to person (if available; "N/A" if no secondary number); ex: landline, family member, etc. *

Do you prefer text or call? *

Text

Call

Date of birth (01/01/2021 format) *

Age *

Do you have access to reliable transportation (at this time we do not offer transportation)?

Yes

Clear selection

Dates that MUST be excluded (i.e., Tuesday mornings, April 25th, mornings, etc.): *

In the last fourteen (14) days, have you experienced any COVID-19 sypmtoms? (fever/chills, cough (dry and/or with phlegm/mucus), difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste/smell, congestion, nausea, vomitting, diarrhea)

I have experienced symptoms of COVID-19 in the last 14 days.

I have NOT experienced symptoms of COVID-19 in the last 14 days.

Clear selection

Check all that apply below: *

I have received a COVID-19 vaccine.

I have had a severe allergic reaction (e.g. anaphylaxis) in the past.

I have a bleeding disorder or I am taking a prescribed blood thinner.

I have a weakened immune system (i.e., due to cancer or HIV infection).

I have received passive antibody therapy as treatment for COVID-19.

I have tested positive for COVID-19 in the last ninety (90) days.

I am pregnant or breastfeeding.

NONE OF THE ABOVE.

Required

I am willing to drive (choose your maximum): *

Up to 30 minutes for my appointment.

Up to 45 minutes for my appointment.

Up to 60 minutes for my appointment.

I can drive anywhere in the state of New Jersey for my appointment.

I understand that Garfield Neighbors cannot guarantee an appointment that is most convenient for me. *

I understand.

I understand that Garfield Neighbors does not provide transportation at this time for vaccination appointments. *

I understand.

I understand that a vaccine appointment is not guaranteed and I agree I will not solely rely on Garfield Neighbors for my COVID-19 vaccination. *

I understand and I agree.

I certify that I am eligible for the vaccination and all answers provided are truthful.

I certify.

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms