COVID-19 Vaccine Pre-registration Form
Faith & Vaccines Project of Resolve Inc. and Laurel Main Street Pharmacy
Faith & Vaccines Project We are committed to partnering with faith-based communities to build trust in vaccines, meeting people where they are, and providing access to vaccination clinics in minority communities. https://www.resolve.ngo/faith_vaccines.htm
Must be Maryland resident only
(All Covid-19 vaccine doses available while supplies last)
Please choose one of our Pop-up vaccine clinic locations
Saturday, January 29th 2022 from 10:30 AM to 12:30 PM at Al-Huda School: 5301 Edgewood Rd, College Park, MD 20740
Al-Huda School - 5301 Edgewood Rd, College Park, MD 20740: Appointment (Please check your junk folder for confirmation email)
Please select preferred Covid-19 Vaccine
Pfizer (Pediatric dose: Ages 5 -11)
Pfizer (Ages 12 and older)
Moderna (Ages 18 and older)
Please select type of dose
Name of Vaccine recipient
Birth Date of Vaccine recpient
Address (Must be Maryland resident)
Street Address Line 2
State / Province
Postal / Zip Code
Race and/or ethnicity
Middle Eastern/North African
Latino or Hispanic
Asian (South Asian, East Asian, Southeast Asian)
Native Hawaiian or Pacific Islander
Two or more
Prefer not to say
Please enter a valid phone number.
Only if applicable
Only if applicable
Covid vaccines are free
Must be Maryland resident. Please bring an ID and/or insurance card if available. Covid vaccine card for second doses and boosters. No one will be turned away for Covid vaccine unless deemed ineligible due to not meeting health criteria and/or recommended guidelines, while supplies last.
Do you have any chronic health condition?
Please indicate all health issues that are considered within the risk group
Please list down your allergies
Have you been diagnosed with COVID-19?
If you have had covid in the past, when was your diagnosis?
I hereby declare that all the given information are accurate.
Signature (Perent/Guardian for minor)
Should be Empty: