Merritt-Kaiser Covid Vaccination Registration Form

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Merritt College and Kaiser Permanente are partnering together to help students thrive!

If you would like to receive your COVID-19 vaccine on Saturday June 19th at Merritt College, please complete the registration form below. Kaiser will be offering both the Pfizer and Johnson&Johnson vaccines. Please note that you do not need to be a Kaiser Member to receive your vaccine.

You will receive an email confirming your vaccine appointment time slot prior to the event. We will do our best to accommodate your first choice timeslot, but note this is not guaranteed. Thank you!

Full Name (First Middle Last) *

Age (Must be 18+) *

Date of Birth *

YYYY

Is this vaccine for you or someone else? *

Self

Someone Else

For my child (age 12+)

If vaccine is for someone other than yourself, please list the names and ages of the individuals you are registering.

Student ID# (if applicable)

Email Address *

Phone Number *

Have you had a confirmed diagnosis of COVID within the last 2 weeks? *

Yes

Unsure

Do you have a Kaiser Medical Record Number? (Note: You do not need to be a Kaiser Member to receive the Covid vaccine.) *

Yes

Unsure

Select your preferred timeslot: *

If your preferred timeslot is full, please select your 2nd choice. *

Thank you for completing the registration form. If there is anything else you would like to share with us in regards to your health and wellness, please let us know.

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