Vaccination Form | AK Strategies

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At-Home Vaccination Request Form

Get a $100 Prepaid Debit Card free (after Dose 1)

First Name

Last Name

Are you 75 years old or older; a person with a disability; or fully homebound?

Choose a Vaccine

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

Preferred Date & Time:

I agree to share the above information with the City and its partners and that a representative may contact me about my interest in this program.

Thank you for helping us make a difference!

Why AK Strategies?

Vaccination Drive

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All Rights Reserved

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