Vaccine Clinic

The State of New Jersey Immunization Information System is collecting demographic information strictly for the purposes of ensuring equity in distribution of the vaccine.

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First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Sex REQUIRED Male Female Unknown Non-binary Please fill out this field.

Address Type REQUIRED Legal Address Permanent Mailing Home Current or Temporary Please fill out this field.

Street or Mailing Address REQUIRED Please fill out this field. Please enter valid data.

Address (line 2) Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Race REQUIRED American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Island White Other Prefer not to specify Please fill out this field.

Please describe your ethnicity: REQUIRED Hispanic or Latino Not Hispanic Prefer not to specify Please fill out this field.

Email Address REQUIRED Please fill out this field. Please enter an email address.