GRAAHI's MLK Vaccination Clinic
The Grand Rapids African American Health Institute is hosting a Vaccination Clinic at Brown-Hutcherson Ministries for people ages 5 and up. Come celebrate the great work of Dr. Martin Luther King Jr. by protecting yourself and your community!

If you are a parent or guardian filling this out on behalf of someone else, please put the patient's information below.

PLEASE BRING YOUR ID AND INSURANCE CARD. (You will still be able to receive a vaccine if you do not have insurance. Just let the medical staff know upon arrival.)

If you are receiving your first vaccine, your second vaccination appointment will be scheduled at check-in.

After submitting this document, a copy of your responses will be sent to your email. This means your appointment has been confirmed.

See you Monday!
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Email *
Participant's First Name *
Participant's Last Name *
Participant's Date of Birth (mm/dd/yyyy) *
Participant's Phone Number (xxx-xxx-xxxx) *
Participant's Address of Home/Facility (House/ Building Street Number) *if not applicable put N/A
Participant's City, State, ZIP Code *
Participant's Preferred Language *
Participant's Marital Status *
Participant's Sex Assigned at Birth *
Participant's Gender *
Participant's Race *
What vaccination is the participant scheduling? *
Per the FDA: Remember if you have already received the first two rounds of vaccinations (from Moderna) or the single Johnson & Johnson vaccine you can still safely get the Pfizer Booster. If you have already received the first dose of Moderna you can NOT receive the Pfizer vaccine for your second dose.
How did you hear about this clinic? *
I agree to future communications from GRAAHI
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