STRIDE COVID Vaccine Registration (Short)

1
I do hereby give consent to diagnostic, treatment, counseling services from the clinical staff of STRIDE (Medical and Behavioral). I understand that there are certain hazards and risks connected with forms of treatment and my consent is given with this knowledge.* This field is required.
YESNO
2
I hereby acknowledge that I have reviewed the Notice of Privacy Practices and Patient Bill of Rights and Responsibilities on the STRIDE public website. Notice of Privacy Practices Patient Rights and Responsibilities
YESNO
3
Your name* This field is required.
First Name
Last Name
4
Your date of birth (mm/dd/yyyy)* This field is required.
5
Your phone number (mobile preferred)* This field is required.
6
Your email address
example@example.com
7
Your home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Please select the priority group you fall under:* This field is required.
People 65 years and older
Long term healthcare resident
Healthcare worker
Dental care worker
First responders
Law enforcement/public safety
School Employee
None
9
Have you been seen at STRIDE in the last 3 years?
YESNO
10
Do you have medical insurance?
YESNO
11
Photo ID (Driver’s License, State Issued ID, etc.)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Medical Insurance Card (If applicable)Medical insurance is not required. If you do not have medical insurance or your medical insurance does not cover the vaccine you will not be billed.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
Verification Document (Badge from Qualifying Employer, Vaccine Eligibility Letter etc.)No verification document is required if you are qualifying based on age.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
We're sorry, we cannot add you to the waitlist at this time. Please check back at a later date.
15
This will end your registration.
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