VIP Registration Community Memorial Baptist Church 7/16

132 Waverly St, Yonkers, NY 10701

Date/Time:

July 16, 2022 | 9AM – 3PM

"*" indicates required fields

Patient's Name/Nombre del Paciente*

First Last

Address/Dirección

Street Address Address Line 2 City State ZIP Code

Personal Phone Number/Número de teléfono

(may be necessary for delivering messages)

Services Needed/Servicios Necesarios*

COVID-19 Testing

COVID-19 Vaccine or Booster

Flu Shot

Other

Age of Patient/Años de Paciente*

12 & older

5-11

4 or under

Email Address/Dirección de Correo Electrónico*

(may be necessary for sending documents)

Enter Email Confirm Email

Phone

This field is for validation purposes and should be left unchanged.