Sensory-Friendly Vaccine Clinic

Additional Questions

Please complete the following questions to complete registration for your Sensory-Friendly Vaccine Clinic appointment.

Please contact us if you have any questions or concerns.

Name*
First Last
Email*
Parent or Guardian's First Name*
Gender*
Race*
Ethnicity*
Industry*
State and federal nondiscrimination laws require medical providers to make sure that people with disabilities have the same access to medical care as people without disabilities. Please let us know if you require one or more of the following accommodations at your vaccine appointment.
- I do not require any accommodation during my appointment
- I require a companion or supporter to accompany me
- I require a service animal to accompany me
- I require extra time for my appointment
- I require assistance with reading or completing paperwork
- I require a qualified sign language interpreter
- I require an assistive listening device
- I require material in the following alternative format: Braille, large print, audio, electronic format, another alternative format
- I require access to a restroom
- I require a place to sit if standing for long periods is required
- I require accommodations not listed above
Please describe the accommodations needed
Is there anything else you would like us to know about the accommodations you are requesting?
Are you experiencing homelessness?*
Please select one.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If Yes, Is the place where you sleep a house/apartment, emergency shelter, tent/encampment, vehicle, or on the street?*
Do you currently have any of the following conditions that put you at the highest risk for extreme complications from COVID-19? Cancer, current with debilitated or immunocompromised state | Chronic kidney disease, stage 4 or above | Chronic pulmonary disease, oxygen dependent | Down syndrome | Immunocompromised state from solid organ transplant | Pregnancy | Sickle cell disease | Heart conditions, excluding hypertension | Severe obesity with a Body Mass Index >= 40 kg/m2 | Type 2 diabetes mellitus with hemoglobin A1c level greater than 7.5%*
- Yes
- No
Do you currently have a physical or mental disability that is so severe and high-risk that one of the following applies: 1) a COVID-19 infection is likely to result in severe, life-threatening illness or death; OR 2) acquiring COVID-19 will limit your ability to receive ongoing care or services vital to your well-being and survival; OR 3) providing adequate and timely COVID care will be particularly challenging as a result of your disability?*
- Yes
- No

Sensory-Friendly Vaccine Clinic

Please complete the following questions to complete registration for your Sensory-Friendly Vaccine Clinic appointment.

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