樂活50加免費疫苗接種
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First Name 名 (English) *

Last Name 姓 (English) *

Cell Phone Number 手機號碼 (Can receive and send text messages可收發短信） *

Zip Code of My Residence 居住地址的郵政編碼 *

City I live in 居住的城市 *

DOB mm/dd/yy 我的出生月/日/年 *

Gender Identity 我的性別 *

Male 男性

Female 女性

Other 其他 Other 其他

Please select the vaccine(s) from the below choices
請勾選您想接種的單一疫苗或疫苗組合： *

Influenza 流感疫苗

Covid-19 (Pfizer) 新冠疫苗(輝瑞）

Covid-19 (Moderna) 新冠疫苗(默德納）

Influenza 流感 + Covid-19(Pfizer) 新冠(輝瑞）

Influenza 流感 + Covid-19(Moderna) 新冠(默德納）

* I understand and agree that event organizer may use my images/photos/videos taken at the event for presentation under any legal condition. 我了解並同意活動主辦方可合法使用我的形像/照片/視頻。

-This project is supported by the Administration for Community Living(ACL) of the U.S. Department of Health and Human Services(HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL, HHS, or the U.S. Government.

-The mobile vaccine team is supported and arranged by Los Angeles County Department of Public Health.

-Consult your medical healthcare providers for any vaccine-related questions or concerns.

樂活50加免費疫苗接種FREE Vaccination Sign Up

樂活50加免費疫苗接種
FREE Vaccination Sign Up