Covid-19 Vaccine Clinic
April 7, 2021
Registration Form

Everyone registering for the vaccine clinic must have one of the following forms of insurance

Lafayette Employee (Required) *

First

Last

Insurance Provider (Lafayette Employee) *

Preferred Location (Required) *

Email (required) *

Contact Phone Number (required) (numbers only) *

Number of Caregivers also requesting the shot

Caregiver 1

First

Last

Insurance Provider (Caregiver 1)

Caregiver 2

First

Last

Insurance Provider (Caregiver 2)

Caregiver 3

First

Last

Insurance Provider (Caregiver 3)

179 Gaywood Drive
Manchester, MO 63021

636-227-5666

Covid-19 Vaccine ClinicApril 7, 2021Registration Form