Vaccination Pilot Program Registration Rivers of Life Pilot Program - Vaccination Pre-registration Step 1 of 2 50% Membership NumberEnter your (or your family member's) church membership number. If you are not a member of Rivers of Life Church Ministries, you may leave this blank. Membership is NOT REQUIRED to participate. Name* First Last Are you a current state of Florida resident?*Please note: All participants must be a Florida resident and provide proof of residency at check-in. Yes No Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemalePrefer not to sayRace*AsianBlack or African AmericanWhiteHispanic / LatinoNative Hawaiian or Other Pacific IslanderPrefer not to sayEthnicityHispanicNon-HispanicOther EthnicityPrefer not to sayPhone*Email*Be sure your email address is correct, as it will be used to send a copy of your registration form to you. Enter Email Confirm Email Are you feeling sick or experiencing any symptoms related to COVID-19?*Common symptoms related to COVID-19 include (but are not limited to) the following: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea Yes No Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?* Yes No Are you currently awaiting results for a COVID-19 test?* Yes No Have you ever received a dose of COVID-19 vaccine?* Yes No Which vaccine product did you receive?* Pfizer Moderna Janssen (Johnson & Johnson) Have you received ANY vaccine in the last 14 days?* Yes No Do you have allergies to medications, food, a vaccine component, or latex?* Yes No Statement of Consent* By selecting this checkbox, I agree that I am eligible to receive the COVID-19 vaccine based on the guidelines established by the state of Florida. I acknowledge that I have answered the questions honestly and to the best of my ability and that my information will be sent to FEMA officials for pre-registration purposes.CAPTCHA