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COVID-19 Vaccine Event Sign Up Sheet-Desoto ISD January 29 & February 19
Supported by Baylor Scott & White Health and Wellness Center
Organization
*
Please Select
Desoto ISD, 620 S. Westmoreland Road, DeSoto, TX 75115
Last Name
*
First Name
*
Middle Name
Phone Number
*
Please enter a valid phone number.
12 years and older
*
Please Select
Yes
No
Birth Date
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2024
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Year
First , Second, or Booster Vaccine dose
*
Please Select
First dose
Second dose
Booster dose
Date
*
-
Month
-
Day
Year
Date
Appointment Time (Saturday, January 29 2022)
Please Select
9:00-9:30 AM
9:30-10:00 AM
10:00-10:30 AM
10:30-11:00 AM
Appointment Time (Saturday, February 19 2022)
Please Select
9:00-9:30 AM
9:30-10:00 AM
10:00-10:30 AM
10:30-11:00 AM
Sex
Please Select
Female
Male
Other
City
*
State
*
Street Address
Zip Code
*
County
*
Text capabilities
*
Please Select
Yes
No
Required: Opt-in or Opt-out from Baylor Scott & White Health and Wellness Center Would you like to receive appointment reminders through text messaging? There is no additional fee for being part of this program. Please check YES to enroll or NO to decline. You may text STOP at any time to opt-out when text messages are received. There is no additional fee for being part of this program. Messages are not secure and you may opt-out at any time.
*
Please Select
Yes
No
Email Address
*
Race
Black or African American
Hispanic or Latino
American Indian or Alaska Native
White
Asian
Native Hawaiian or Other Pacific Islander
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
How did you hear about this event?
*
Flyer
Outreach
Word of mouth
Advertising in newspaper
Walk-in
Outdoor signage
Social media
Vaccine education event
Another community vaccine event
Scanned QR code
Other
Consent to vaccinate. Consent form will need to be completed the day of the appointment.
*
Please Select
Yes
No
Submit
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