BABER AME Church - Public Link

FOR INDIVIDUALS CURRENTLY ELIGIBLE UNDER NEW YORK STATE GUIDELINES RECEIVING 1ST DOSE ONLY!
This link is for individuals who are currently eligible for vaccination in New York State for any reason scheduling a first-dose appointment for COVID-19 vaccination. If you are not able to self-attest to being eligible, please do not use this link.

Your Email Address *

Confirmation of appointment will be sent to this email.

Pick a Vaccine Site

# People You Are Scheduling: Max: 1

Pick a Date *

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Recipient

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First Name *

Last Name *

Middle Name

Date of Birth *

Race *

Ethnicity *

Gender *

Phone * Copy From Person #1

Email * Copy From Top Email

Address * Copy From Person #1

Address (Line 2, Apt, Etc.)

City *

State *

Zip *

Special Accommodations Needed (wheelchair access, translator, etc.)

Mother's First Name (if age < 19)

Mother's (Maiden) Last Name

Eligibility Group

Bring proof of eligibility with you to appointment!

Select the eligible vaccine priority group you belong to * More Info

Emergency Contact (optional)

First Name

Last Name

Middle Name

Phone #

Relationship to Recipient

Primary Care Provider (optional)

First Name

Last Name

Phone

City

State

Zip

Screening Questions

Are you currently under the age of 18? *

Yes No Unknown

Are you feeling sick today? *

Yes No Unknown

In the last 10 days, have you had a positive COVID-19 test or been told by a healthcare provider or health department to isolate or quarantine at home? *

Yes No Unknown

Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)? *

Antibody therapy and convalescent plasma for COVID-19 is a medical treatment provided to some people with COVID-19 infection.

Yes No Unknown

Have you ever had an immediate allergic reaction, such as hives, facial swelling, or difficulty breathing or anaphylaxis, to any vaccine or shot or to any component of the COVID-19 vaccine, such as PEG or polysorbate? *

This allergy does not apply to mild allergic reactions such as rash only and does not include allergies that are not related to a vaccine (for example it does not include allergies to: pets, venom, environmental, latex or oral medications).

Yes No Unknown

Have you had any vaccines in the past 14 days (2 weeks) including flu shot? *

This includes tetanus, hepatitis A, mumps, flu or any other vaccine.

Yes No Unknown

Are you pregnant or considering becoming pregnant? *

Yes No Unknown

Do you have a bleeding disorder or are you currently taking a blood thinner? *

Yes No Unknown

Do you have cancer, leukemia, HIV/AIDS, a history of autoimmune disease or any other condition that weakens the immune system? *

Yes No Unknown

Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments? *

Yes No Unknown

Have you ever received a dose of the COVID-19 vaccine? *

Yes No Unknown

I have read the entire list of priority groups for COVID-19 vaccination. I hereby certify that I am part of a priority group identified for COVID-19 vaccination, for the week that I am being vaccinated. I further agree that by clicking "I AGREE" and submitting this form, I am placing the legal equivalent of my handwritten signature on such certification. *

I AGREE

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YOU WILL NOT BE ABLE TO EDIT THIS INFORMATION AFTER CLICKING THE SUBMIT BUTTON BELOW. PLEASE MAKE SURE ALL INFORMATION IS CORRECT.

Monroe County, NY COVID-19 Vaccine Registration Form

Recipient

Eligibility Group

Emergency Contact (optional)

Primary Care Provider (optional)

Screening Questions