Vaccination Clinic Registration - Disability Advocacy Center

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DAC Vaccination Clinic Registration

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DAC Vaccination Clinic Registration

Thanks for your interest in attending the Vaccination Clinic at Disability Advocacy Center! Please fill out this form to register.

First Name

Last Name

Phone

Email

Address

Date of Birth (m/d/y)

What is your gender?

Woman

Man

Nonbinary/Genderqueer/Genderfluid

I prefer not to answer

Some other gender identity (please specify below)

Text Input

Which race, ethnicity, or origin describes you?

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino or Spanish Origin

Middle Eastern or North African

Native Hawaiian or Other Pacifc Islander

White

I prefer not to answer

Some other race, ethnicity, or origin (please specify below)

Text Input

Do you identify as disabled?

Yes

No

Unsure

Prefer not to answer

How did you hear about the Vaccination Clinic?

DAC Staff

Facebook

Flyer

Friends or Family

Guilford County Website

Other

Please state the other way that you heard about the Vaccination Clinic.

Which dose of the vaccine are you getting?

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DAC Vaccination Clinic Registration

ABOUT DAC

Transforming Lives from Disabilities to Possibilities

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