Holliday Memorial: Vaccine Registration Form
Bethany Community Ministries is hosting a COVID-19 Vaccination Event at the Holliday Memorial Health Fair. Please complete this form to pre-register for the event. Children under 18 must be accompanied by an adult to receive the vaccine.

Event Date: Saturday, July 30, 2022
Location: Holliday Memorial AME Zion Church
600 Talbot Street, Braddock, PA  15104
Time: 2:00 pm to 4:00 pm
Eligibility: Ages 5+
Cost: FREE

Vaccines Available:
- Pfizer (2-step): Ages 5 & up
- Moderna (2-step): Ages 18 & up

Health Screenings will be available!
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First Name *
Last Name *
Phone Number *
Phone Type *
Email Address *
Zip Code *
Date of Birth *
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Race *
Required
Ethnicity *
Gender *
Who is your insurance provider? *
Which vaccine do you want to receive? *
Which dose will you be receiving? *
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