Please let us know if you are changing your status regarding our next vaccine clinic

It would be very helpful to us if you would respond on the very short form below.

Thank you.

Your Name

First Name

Last Name

Your EMAIL address

NOTE: If this email address is shared with another person who had signed up for this clinic, please put their FULL NAME at the end of this form.

Phone number

The best number to reach you.

(###)

###

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Would you like to be added to the list for any upcoming vaccine clinic?

Yes, please keep me informed on upcoming Wintergreen-Nelson clinics.

No, I'll look into other opportunities to get the vaccine.

No, I'm getting the vaccine elsewhere. Thank you.

Other. (You can use the field below if you like.)

Anything else we need to know?

Thanks again!