COVID-19 Vaccination Survey (Age 70+) – Indo-Canadian Community Centre

COVID-19 Vaccination Survey (New)
(Age 70 Years and Above and have a Severe Underlying Health Condition)

Click here to see the list of underlying health conditions.

Your First Name

Your Last Name

Gender

M F

Your Age

Your Email Address

Your Phone Number

Your Area Postal Code

Will you need transportation to get vaccinated?

Yes No Maybe

Do you have a caregiver at home?

Yes No

If yes, please provide the full name, gender, and age of the caregiver.