Alliance of Disability Advocates · COVID -19 Vaccine Form

Full-Name

*

Contact Information

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Preferred Method of Contact

*

Phone

Email

Verify Email

Phone

Have You Received The COVID-19 Vaccine?

*

Yes

No

Are there any Barriers Preventing You From Getting the COVID-19 Vaccine?

For other, please describe your barrier in the comment box below.

Transportation

Prior Commitments

Need PCA Assistance

Appointment Scheduling

Unaware of Vaccine Locations

Unaware of Resources to Meet My Needs

Other

Do You Need Help Getting A Booster?

*

Yes

No

If You Have Children That Qualify for the COVID-19 Vaccine, Would You Like Them To Be Vaccinated As Well?

*

Yes

No

Please Describe Any Further Concerns or Barriers You Are Facing Regarding The COVID-19 Vaccine.