SARS-COV-2 Vaccine Notification Survey

SARS-COV-2 Vaccine Notification Survey

"COVID-19 Vaccine Notification and Distribution Survey"
Community Member's Name *

First Name Last Name
Community Member's Email
example@example.com
Community Member's Cell Phone Number

Area Code Phone Number
Community Member's Home Phone Number *

Area Code Phone Number
Are you currently employed in Polk County, NC

Yes, employer is located in Polk County, NC or I work from home No, I am a resident of Polk County, NC and employed outside of the county Unemployed and a Resident of Polk County, NC

Do you currently volunteer in the Polk County community for any of the following: Healthcare, Homeless Shelter, School/Child Daycare Center, EMS, Firefighter, and/or First Responder

Yes I volunteer No

Parent or Guardian Consent Required: Because you will not be 18 years of age by 12/15/2020
Parent's or Legal Guardian's Name *

First Name Last Name
Parent's or Legal Guardian's Phone Number *

Area Code Phone Number
Parent's or Legal Guardian's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent's or Legal Guardian's Signature *

Clear
Date Signed *

Month Day Year
Date

Parent or Guardian Consent Required: Because you will not be 18 years of age by 12/15/2020