City of Pharr COVID-19 Vaccine Interest Form

City of Pharr COVID-19 Vaccine Interest Form

It is our intention to gather data on individuals that are interested in receiving the COVID-19 vaccine. Filling out this form WILL NOT register you to receive a vaccine. We will not share any of your information as it is strictly used to conduct informed planning for vaccinations.
Patients Full Name: *

First Name Middle Name Last Name
Address *

Street Address

Apt. / Suite/ Lot #

City State

Zip Code
Date of Birth: *

Month Day Year
Phone: *
Please enter a valid phone Number.
Email *
example@example.com
Gender: *

Male Female
Race: *

Hispanic or Latino Not Hispanic or Latino
Ethnicity: *

American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Asian White Black or African American Other
Are you one of the following?: *

First Responder Healthcare Worker 65 years or older and bedridden or homebound Person under age of 65 with underlying medical conditions Resident of a care facility or adult day care Veteran No, I am not any of the above
Are you one of the following?: *

First Responder Healthcare Worker Person under age of 65 with underlying medical conditions Resident of a care facility or adult day care Veteran No, I am not any of the above
Should be Empty: