K. Leroy Irvis: Vaccine Registration
Bethany Community Ministries is hosting a COVID-19 Vaccination Clinic at K. Leroy Irvis Towers in partnership with the brothers of the Pittsburgh KAPPA ALPHA PSI alumni chapter and Allegheny Health Network. Please complete this form to pre-register for the event. Children under 18 must be accompanied by an adult to receive the vaccine.

ENJOY A FREE DINNER AT THE EVENT!

Vaccines Available:
- Bivalent COVID Booster (Pfizer): Ages 12+

Date: Monday, November 21, 2022
Location: K. Leroy Irvis Towers
715 Mercer Street, Pgh, PA 15219
Time: 3:00 pm to 7:00 pm
Cost: FREE!

Free health screenings on site!
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Phone Number *
Phone Type *
Email Address *
Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Race *
Ethnicity *
Gender *
Who is your insurance provider? *
Which COVID vaccine do you want to receive? *
Which dose will you be receiving? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bethany Community Ministries. Report Abuse
Google Forms