Waiting List For Receiving Booster COVID Vaccine at CCACC 新冠疫苗加強劑注射意願調查表
CCACC is working with Montgomery County to help with COVID vaccination efforts. If you would like to receive updated further information about this event, please leave your contact information here.

CCACC 正與蒙郡合作提供新冠疫苗注射事宜。你如果想得到這方面的最新消息，請你留下通訊信息。

You can subscribe our e-newsletter here 你也可以訂閱我們的電子通訊：

​https://mailchi.mp/da711d65b982/3lrw8lsdwc
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Official Last Name 姓： *
Official First Name 名： *
Middle Initial: 中間名
Date of Birth 生日： *
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Email Address 電郵地址： *
Phone Number 電話號碼: *
Are you a Montgomery County Resident? 您是否為蒙郡居民? *
Which vaccine brand did you receive previously? 您之前接種的疫苗品牌為何? *
Which vaccine brand do you want to receive ? 您此次想接種的疫苗品牌為何? *
Required
When did you receive your second dose of COVID vaccine? 您的第二針新冠疫苗是何時注射的? *
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Gender 性別 *
Address 住址 *
City 城市 *
Zip code 郵遞區號 *
County 郡 *
If eligible, our staff will call you back or email you to complete the registration process. Thank you for completing our survey! 如果您符合資格,我們將以電話或電郵聯繫您,完成註冊的程序。謝謝您完成我們的問卷!
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