1. First name
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2. Last name
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3. Contact phone number (including area code)
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5. Age
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5 to 11 (please read red text below)
12 to 17
18+
We are unable to provide vaccinations for children ages 5 to 11 yet as we are awaiting guidance from the Alameda County Public Health Department. If you have a pediatrician, please try to schedule a vaccination with them first or visit MyTurn (Click here ) to find available public locations that do not require insurance. 5. Date of birth (In format DD-MM-YYYY)
Click on the calendar symbol to the right to use the automated date function.
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Today M-D-Y
6. What gender do you identify as?
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Male
Female
Transgender
Non-binary
Other
Prefer not to disclose
7. What race/ethnicity do you identify as? Please select all that apply.
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American Indian or Alaska Native
Asian
Black or African American
Latinx or Hispanic
Middle Eastern
Native Hawaiian or Pacific Islander
White or Caucasian
Unknown/Prefer Not to Disclose
6. Do you live or work in Alameda County?
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Yes
No
As our vaccine allocation comes from the Alameda County Health Department, we unfortunately cannot vaccinate anyone who does not live or work in Alameda County. Please exit this form and visit MyTurn (Click here ) to schedule an appointment near you. Please list the city where you live.
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7. Which of our vaccine locations are you interested in?
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Center of Hope Community Church from 10:30 AM to 2:30 PM - occurs every other Thursday (Next date: 11/11)
Castlemont Highschool from 2 to 5 PM - occurs every other Thursday (Next dates: 11/4, and 11/18)
Children's Hospital Oakland Research Institute (CHORI) from 9:30 AM to 1:30 PM -occurs every other Friday (Next date: 11/12)
Home vaccination
McClymonds High School from 1130 to 4 PM - occurs every other Friday (Next dates: 11/5, and 11/19)
AKOMA Market from 10 to 3 PM (Next date: 11/7)
7. Which of our vaccine locations are you interested in?
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Castlemont Highschool from 2 to 5 PM - 11/18
McClymonds High School from 1130 to 4 PM - 11/19
Turkey Day (Verdese Carter Park) 930 to 230 PM - 11/20
Paradise Baptist Church 9 to 12 PM - 11/27
Home vaccination
7. Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 1030 to 230 PM - 12/09
CHORI (Children's Hospital of Oakland Research Institute) from 930 to 130 PM - 12/10
Castlemont High School from 2 to 5 PM - 12/16
McClymonds High School from 1130 to 4 PM - 12/17
Mike's Night from 6 to 9 PM - 12/10, 12/17
Home vaccination
7. Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 1030 to 230 PM - 1/06
CHORI (Children's Hospital of Oakland Research Institute) from 930 to 130 PM - 1/07
Castlemont High School from 2 to 5 PM - 1/13
McClymonds High School from 1130 to 4 PM - 1/14
AKOMA Market 10 AM to 3 PM -1/16
Home vaccination
7. Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 1030 to 230 PM - 1/06
CHORI (Children's Hospital of Oakland Research Institute) from 930 to 130 PM - 1/07
True Vine Ministries 10 AM to 2 PM - 1/08
Castlemont High School from 2 to 5 PM - 1/13
McClymonds High School from 1130 to 4 PM - 1/14
AKOMA Market 10 AM to 3 PM -1/16
Home vaccination
7. Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 1030 to 230 PM - 1/20
True Vine Ministries 10 AM to 2 PM - 1/21
Castlemont High School from 2 to 5 PM - 1/13
McClymonds High School from 1130 to 4 PM - 1/14
Roots Community Clinic from 10 AM to 2 PM - 1/15
AKOMA Market 10 AM to 3 PM -1/16
Home vaccination
7. Which of our locations are you interested in?
* must provide value
Castlemont High School from 2 to 5 PM - 1/13
Roots Community Clinic from 10 AM to 2 PM - 1/15
AKOMA Market 10 AM to 3 PM -1/16
Center of Hope Community Church from 1030 to 230 PM - 1/20
True Vine Ministries 10 AM to 2 PM - 1/21
Castlemont High School from 2 to 5 PM - 1/27
McClymonds High School from 1130 to 4 PM - 1/28
Roots Community Clinic from 10 AM to 2 PM - 1/29
Home vaccination
Which of our locations are you interested in?
* must provide value
Castlemont High School from 2 to 5 PM - 1/27
McClymonds High School from 1130 to 4 PM - 1/28
Roots Community Clinic from 10 AM to 2 PM - 1/29
Center of Hope Community Church from 1030 to 230 PM - 2/3
True Vine Ministries 10 AM to 2 PM - 2/4
AKOMA Market 10 AM to 3 PM -2/6
Castlemont High School from 2 to 5 PM - 2/10
McClymonds High School from 1130 to 4 PM - 2/11
Center of Hope Community Church from 1030 to 230 PM - 2/17
True Vine Ministries 10 AM to 2 PM - 2/18
Castlemont High School from 2 to 5 PM - 2/24
McClymonds High School from 1130 to 4 PM - 2/25
Home vaccination
Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 1030 to 230 PM - 2/17
True Vine Ministries 10 AM to 2 PM - 2/18
Castlemont High School from 2 to 5 PM - 2/24
McClymonds High School from 1130 to 4 PM - 2/25
Home vaccination
Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 1030 to 230 PM - 2/17
True Vine Ministries 10 AM to 2 PM - 2/18
Castlemont High School from 2 to 5 PM - 2/24
McClymonds High School from 1130 to 4 PM - 2/25
Raimondi Park 1800 Wood St 12 PM - 3 PM - 2/26
Home vaccination
Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 10:30 to 2:30 PM - 3/3
True Vine Ministries 10 AM to 5 PM - 3/4
AKOMA Market 10 AM to 3 PM -3/6
Castlemont High School from 2 to 5 PM - 3/10
McClymonds High School from 11:30 to 4 PM - 3/11
Center of Hope Community Church from 10:30 to 2:30 PM - 3/17
True Vine Ministries 10 AM to 5 PM - 3/18
Castlemont High School from 2 to 5 PM - 3/24
McClymonds High School from 11:30 to 4 PM - 3/25
Center of Hope Community Church from 10:30 to 2:30 PM - 3/31
Home vaccination
Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 10:30 to 2:30 PM - 3/3
True Vine Ministries 10 AM to 4 PM - 3/4
AKOMA Market 10 AM to 3 PM -3/6
Castlemont High School from 2 to 5 PM - 3/10
McClymonds High School from 11:30 to 4 PM - 3/11
Center of Hope Community Church from 10:30 to 2:30 PM - 3/17
True Vine Ministries 10 AM to 4 PM - 3/18
Castlemont High School from 2 to 5 PM - 3/24
McClymonds High School from 11:30 to 4 PM - 3/25
Center of Hope Community Church from 10:30 to 2:30 PM - 3/31
Home vaccination
Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 10:30 to 2:30 PM - 3/31
True Vine Ministries 12 AM to 4 PM - 4/1
AKOMA Market 10 AM to 3 PM -4/3
Center of Hope Community Church from 10:30 to 2:30 PM - 4/14
True Vine Ministries 12 AM to 4 PM - 4/15
AKOMA Market 10 AM to 3 PM -4/17
Castlemont High School from 2 to 5 PM - 4/21
McClymonds High School from 11:30 to 4 PM - 4/22
Earth Day Celebration Mosswood Park 10 AM to 2 PM - 4/23
Center of Hope Community Church from 10:30 to 2:30 PM - 4/28
True Vine Ministries 12 AM to 4 PM - 4/29
Home vaccination
Which of our locations are you interested in?
* must provide value
Center of Hope Community Church from 10:30 to 2:30 PM - 3/31
True Vine Ministries 12 PM to 4 PM - 4/1
AKOMA Market 10 AM to 3 PM -4/3
Center of Hope Community Church from 10:30 to 2:30 PM - 4/14
True Vine Ministries 12 PM to 4 PM - 4/15
AKOMA Market 10 AM to 3 PM -4/17
Castlemont High School from 2 to 5 PM - 4/21
McClymonds High School from 11:30 to 4 PM - 4/22
Earth Day Celebration Mosswood Park 10 AM to 2 PM - 4/23
Center of Hope Community Church from 10:30 to 2:30 PM - 4/28
True Vine Ministries 12 PM to 4 PM - 4/29
Home vaccination
Which of our locations are you interested in?
* must provide value
AKOMA Market 11 AM to 5 PM -5/1
Castlemont High School from 2 to 5 PM - 5/5
McClymonds High School from 11:30 to 4 PM - 5/6
Center of Hope Community Church from 10:30 to 2:30 PM - 5/12
True Vine Ministries 12 PM to 4 PM - 5/13
AKOMA Market 11 AM to 5 PM -5/15
Castlemont High School from 2 to 5 PM - 5/19
McClymonds High School from 11:30 to 4 PM - 5/20
Center of Hope Community Church from 10:30 to 2:30 PM - 5/26
True Vine Ministries 12 PM to 4 PM - 5/27
Home vaccination
8. What dose are you interested in?
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1st Dose
2nd Dose
Booster Shot
Supplemental Dosage
8. What dose are you interested in?
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1st Dose
2nd Dose
Booster Shot
2nd Booster Shot
Supplemental Dosage
Which Vaccine do you want to receive?
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Moderna (ages 18+)
Pfizer (ages 12+)
Pediatric Pfizer (ages 5-11)
How many people in the home (including yourself) need to be vaccinated?
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Please list the zip code where you live.
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9. Are you currently experiencing homelessness/unsheltered?
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Yes
No
Prefer not to disclose
10. Do you live in or have you recently lived in any of the following: homeless shelter, incarceration/detention facility, behavioral health center, long term care facility
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Yes
No
Prefer not to disclose
11. Do you currently work?
* must provide value
Yes
No
Prefer not to disclose
What do you do for work? Please only choose one answer even if you have multiple jobs.
* must provide value
Food and Agriculture (E.g. grocery stores, food trucks, restaurants, pickup/takeout, delivery)
Education and Childcare (E.g. Staff in formal and informal childcare/daycare/education, educational support services and administration; school bus drivers, school crosswalk guards)
Emergency Services (E.g. 911 dispatchers, disaster workers, law enforcement, CPS/APS, security staff, utility workers)
Healthcare (E.g. In-home health services, community health workers, long-term facility workers, etc.)
Transportation and Logistics (E.g. public transit/airport and commercial airlines)
Congregate Settings (E.g. Incarceration/detention facility, homeless shelter, or behavioral health facility)
Janitor
Other Job
Other job, please describe.
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Please list the zip code where you work.
12. Do you have any health conditions?
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Yes
No
Prefer not to disclose
Please select your health condition from the list below. Please only choose one answer even if you have multiple health conditions.
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Cancer
Chronic kidney disease, stage 4 or above
Chronic pulmonary disease with oxygen dependence
Down Syndrome
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies (excludes hypertension)
Solid organ transplant, leading to a weakened immune system
Pregnancy
Severe obesity (BMI greater than or equal to 40 kg/m2)
Sickle Cell Disease
Type 2 Diabetes Mellitus, with a hemoglobin A1C level greater than 7.5%
Other
Other health condition, please describe
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9. How did you hear about Umoja Health? Please write the full name of the individual, organization, etc.
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