Pre-Registration for 60+ in L3S and L6GFor 1 Eligible Senior and 1 Companion to be Vaccinated Together Information for Eligible Senior Please fill out this form to pre-register 1 senior living L3S/L6G and 1 companion. The companion does not have to live with the eligible senior. The companion does not have to live in L3S or L6G. You will be contacted within 24-48 hours with your appointment details by our volunteers. First Name of Eligible Senior * Last Name of Eligible Senior * Date of Birth of Eligible Senior * MM DD YYYY Address of Eligible Senior * Address 1 Address 2 City State/Province Zip/Postal Code Country Email of Eligible Senior * Phone of Eligible Senior * (###) ### #### Information for Companion First Name of Companion Last Name of Companion Date of Birth of Companion MM DD YYYY Address of Companion Address 1 Address 2 City State/Province Zip/Postal Code Country Email of Companion Phone of Companion (###) ### #### Attestation of Priority Group * I attest and confirm that I am born in 1951 or earlier AND I am a resident of the L3S Postal Code. I agree that I will produce verification of my age and residency in the L3S postal code upon arrival at the vaccination site. I understand that if I fail to provide valid identification of age or residency I will be refused entry into the vaccination centre by security. There are no exceptions to this rule. I agree Thank you for your pre-registration.Our volunteers will provide you a reserved appointment slot for you and your companion. Our volunteers will also call you to confirm you date and time.
