Relief App

Minor Participant

Participant consents to having their information shared with appropriate state healthcare agencies.

Anticipated vaccinations

Moderna Covid 6+ years booster bivalent 229
Moderna Covid 12+ years primary monovalent 207
Pfizer Covid 12+ years (gray cap) primary monovalent 217
Pfizer Covid 12+ years booster bivalent 300
Sanofi Pasteur Fluzone, influenza, injectable, quadrivalent, contains preservative, multi-dose vial primary 158

Location

Government Issued ID

Covid Vaccination Card

Minor's First Name

Minor's Middle Name

Minor's Last Name

Minor's Email (optional)

Minor's Phone (required if participant is an adult)

Minor's Social Security Number (SSN optional)

Minor's Date of Birth (mm/dd/yyyy)

Minor's Sex

Minor's Race

Minor's Ethnicity

Select if you do not have health insurance.

Insurance

Health Insurance

Health Insurance (Required only if Other was selected above)

Health Insurance Member ID

Health Insurance Group ID

Health Insurance Plan ID (Optional)

Relationship to Person Insured (self, spouse, child, etc.)

Insurance Card Front

Insurance Card Back

Address

Guardian First Name

Guardian Last Name

Guardian Date of Birth (mm/dd/yyyy)

Guardian Email

Guardian Phone

Address1

Address2

City

State

Zip Code

Minor