Registration for Bergen County

COVID-19 Specific Information
Have you ever tested positive for COVID-19 or has a doctor ever told you that you had COVID-19? *

Yes No
When was your earliest positive test?

Month Day Year
Date
Have you received passive antibody therapy (monoclonal antibodies or convalescent plasma/serum) as a treatment for COVID-19?

Yes No
There is a potential for last minute appointment availability. Would you be interested in and able to get to the New Milford Senior Center (275 River Rd, New Milford, NJ 07646) within 15 minutes of receiving notification? DO NOT COME TO THE SENIOR CENTER UNLESS YOU ARE CALLED. We would be looking for people to who are available on Wednesdays between approximately 4pm-7pm and/or Saturdays between approximately 10am-2pm (You may select more than 1 answer)
Last Minute Appointment Options:

Wednesdays Saturdays Neither

Consents and Permissions
Important Information (all boxes must be selected to continue) *

I hereby certify that the answers provided within this document are truthful and accurate as of the time of filling out this registration. I hereby consent to the Borough of New Milford and/or the Mid-Bergen Regional Health Commission, their employees, authorized third-party providers, and any other entity deemed appropriate, may utilize the information I have provided in this questionnaire in whatever manner necessary to obtain and administer the COVID-19 vaccine, except for selling my information to third parties. I hereby consent to receive telephone calls, email messages and/or SMS communications regarding the COVID-19 vaccine, at a frequency and in a manner deemed appropriate by the Borough of New Milford and/or the Mid-Bergen Regional Health Commission.
Please verify that you are human *
Should be Empty:

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COVID-19 Vaccine Clinic Registration