COVID-19 Vaccination Employee Registration Form

COVID-19 Vaccination Employee Registration Form
After filling up this form, you will be called to confirm the appointment. You will also receive a confirmation email that contains information and instruction about the vaccination process.
Please prepare the following:
1. Face mask
2. Identification ID
3. Company ID
4. Dress appropriately
Employee ID
Employee Name
First NameLast Name
Position/Job Title
Department
Age
Gender
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Job Description
Are you a frontline essential worker?
Select an appointment date and time
Would you like to receiving the COVID-19 vaccine?
Acknowledgment
By signing below, you agree that participation in this vaccination is voluntary. You also agree to follow the steps and process provided by the health care facility in receiving the vaccine.
By signing below, you confirm that you will not receive the vaccine via this employer. You also confirm that you were already encouraged to do so and were educated about the advantages of the vaccine.
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

Acknowledgment