Message Outlines
We Care Team
Ministry Sign Up
About Us
Church History
Dr. Kevin B. Lee
Our Staff
Employment Information
Berean CC Henry
Berean CC Dekalb
Giving
New System (PushPay)
Old System
Gwinnett
DeKalb
Henry County
Christian Ed
Classes
Small Groups
Resources
Berean Gwinnett Forms
Senior Application
Fasting Devotional
Coordinator Hub
Counselor’s Corner
Mental Health Workshop
Events
B
4
Lifestyle
Gallery
Pay For Events
Volunteer Survey
Sermon Archives
CCB
(770) 593-4421 |
2201 Young Road Stone Mountain, GA 30088
Login
Message Outlines
We Care Team
Ministry Sign Up
About Us
Church History
Dr. Kevin B. Lee
Our Staff
Employment Information
Berean CC Henry
Berean CC Dekalb
Giving
New System (PushPay)
Old System
Gwinnett
DeKalb
Henry County
Christian Ed
Classes
Small Groups
Resources
Berean Gwinnett Forms
Senior Application
Fasting Devotional
Coordinator Hub
Counselor’s Corner
Mental Health Workshop
Events
B
4
Lifestyle
Gallery
Pay For Events
Volunteer Survey
Sermon Archives
CCB
Ways to Give
Events
Watch Now
COVID Vaccination
ADD LISTING
RETURN TO DIRECTORY
Click the link below to complete a questionnaire for the Gwinnett COVID-19 Vaccination:
Complete Questionnaire
Gwinnett COVID-19 Vaccination Questionnaire
WELCOME!
This form is a preliminary health screening for those who are interested in receiving a vaccination. Please note that this registration is open to the first 100 people who apply. All registrars after the initial 100 will be placed on a waiting list.
Personal Information
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
*
Email
*
Enter Email
Confirm Email
Date of Birth
*
Gender
*
Select Gender
Male
Female
Race
*
Select Race
Black
White
Asian
American Indian
Native Hawaiian
Multi/Other
Ethnicity
*
Select Ethnicity
Hispanic
Non-Hispanic
Gwinnett Vaccination Pre-Screening Questions
If your response to any of the below statements are Yes, you are not eligible for vaccination.
1. Have you ever had a life threatening allergic reaction after a dose of any vaccine or injectable medication or any immediate allergic reaction of any severity to a previous COVID-19 vaccine or any of its components (including polysorbate)?
*
Select Yes or No
Yes
No
2. Have you had a vaccine within the past 14 days and will NOT receive another vaccine within the next 14 days?
*
Select Yes or No
Yes
No
3. Are you currently under isolation (infected with COVID-19), nor under quarantine, (exposed to someone with COVID-19)?
*
Select Yes or No
Yes
No
4. Are you currently moderately or severely ill?
*
Select Yes or No
Yes
No
5. Have you received monoclonal antibody therapy or convalescent plasma for COVID-19 treatment in the past 90 days?
*
Select Yes or No
Yes
No
6. Do you have a severe (life threatening) allergy to any component of this vaccine as detailed in the Emergency Use Authorization?
*
Select Yes or No
Yes
No
Unfortunately, at this time, we are not able to complete your application for COVID-19 Vaccination Pre-Screening at this site. Please check with your local health department or physician for guidance on receiving COVID-19 vaccinations.
This iframe contains the logic required to handle Ajax powered Gravity Forms.
WordPress Image Lightbox Plugin
X
