Name *

First Name

Last Name

Are you a restaurant employee, including a worker in permitted soup kitchen and congregate meal programs? *

Yes

No

Employer/Work Place Phone Number *

(###)

###

####

Have you received another vaccine within the last 14 days? *

Yes

No

Are you currently acutely ill from known SARS-CoV-2 infection.? *

Yes

No

In the past 90 days have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment? *

Yes

No

Do you have a known history of a severe allergic reaction to a component of the COVID-19 vaccine? *

Yes

No

In the past have you had a severe allergic reaction to a vaccine or injectable therapy (intramuscular,intravenous,or subcutaneous)? *

Yes

No

Are you currently pregnant or breastfeeding/lactating? *

Yes

No

Date of Birth *

MM

DD

YYYY

Home Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

By filling out this form, I have asked Feed the Frontlines NYC to help my schedule an appointment to receive a COVID-19 vaccine in New York State. In so doing, I am a) collecting and submitting personal information including my name, date of birth, and contact information; b) submitting my confirmation that I am eligible for the vaccine. I understand Feed the Frontlines NYC volunteers will view this personal information required to make a vaccine appointment and underwrite any potential risk associated with that. *

Yes, I understand and agree.

I certify that, to the best of my knowledge, the above information I provided is correct. I understand that I am providing this information to vaccine providers under penalty of perjury and that I will be expected to provide proof of identification and eligibility at my vaccination appointment. *

Yes, I understand and agree.

I understand and agree that the volunteers are not affiliated with the vaccine providers; that they are not responsible for verifying the accuracy of the information I have provided or my eligibility for the vaccine; and that I am solely responsible for the information they have transmitted on my behalf. *

Yes, I understand and agree.