COVID - 19 Vaccination Registration Form

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

Complete this form to receive a call to schedule your vaccine appointment at New York- Presbyterian Morgan Stanley Children's Hospital, Wintergarden Vaccination Hub, 3959 Broadway (Corner of 165th Street) NY, NY 10032. Vaccine Appointments are available on the following days and times: Tuesdays 9am-7pm, Thursdays 9am-7pm, Fridays 9am-7pm and Saturday 3pm-7pm. **HOWEVER, you MUST complete this form to have an appointment scheduled. ***You must be 12+ and live within New York State.***

First Name *

Last Name *

Phone Number *

E-mail *

Address *

City *

State *

Zip Code *

Date of Brith *

YYYY

Have you been previously tested for COVID-19?

Yes

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Harlem Pride. Report Abuse

Forms