Covid Vaccine Registration Form

Wednesday October 28th — 10:00 am to 2:00 pm

Thank you for Registering

Thank you for choosing to take part in our BHCC vaccine clinic. Please register each person separately. This way, we'll get an accurate count and know exactly how many vaccines to prepare for.

This year, in an effort to support our government's "Buy Canadian" initiative, we are only offering the Canadian made Moderna vaccine.

Name of Registering Resident *

First

Last

Address in Briar Hill / Green Briar *

Phone

Email of Resident *

Vaccine Supplier
Moderna

Disclaimer:

Thank you for supplying your name, email address, and phone number. This data is retained for the sole purpose of your vaccine clinic registration. The BHCC will take every precaution to protect your privacy. By submitting this application you understand & accept the Disclaimer and consent to the BHCC contacting you if we require further information.

Please do not forget to bring your Health Card and reading glasses (if required).
You will have to fill out a form before getting your vaccine.

Briar Hill Community Centre