This website uses scripting to enhance your browsing experience.
Enable JavaScript
in your browser and then reload this website.
This website uses resources that are being blocked by your network. Contact your network administrator for more information.
Mercyhurst University
COVID-19 Vaccine - Open Registration
Loading...
The Commonwealth of Pennsylvania Department of Health has accelerated the phased rollout of COVID-19 vaccine eligibility.
To prepare for potential on-campus vaccine clinics or reserved windows for members of our community at clinics held within the community, please complete the below form to register your interest in vaccination.
If, after registering, you later
upload vaccination documentation
, we will automatically remove you from the list of community members awaiting vaccination.
Registration for the April 13 clinic is now closed, but please continue to sign up. If we have extra doses, we will contact you by mobile phone.
About You
First Name
Last Name
Permanent Home Address
Permanent Home Address
Country
Street
City
Region
Postal Code
Email Address
(if you are currently affiliated with Mercyhurst, please use your Mercyhurst email address)
Mobile Phone
[HIDDEN] Device Type
Email Address (External)
Email Address (Mercyhurst)
Home Phone
Mobile Phone
Mobile Phone (No SMS)
Other Phone
Role
Current Student
Future Student
Faculty
Staff/Administration
Mercyhurst Family Member
Aramark Employee
Parkhurst Employee
Colleague ID Number
*
(Student/Employee ID Number)
You must enter all seven digits (including any leading zeros). Your ID number can be found on your OneCard or in
Self Service
.
Demographic Information
Birthdate
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Sex
Male
Female
Another
If you would like the opportunity, we invite you to share more about your gender identity here:
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
White
Are you Hispanic or Latino?
Yes
No
Insurance Information
Health insurance is not required to receive the vaccine, but many providers will attempt to bill your insurance when possible. If you have your health insurance information, enter it below. If you do not have it, you may leave these fields blank.
Health Insurance Provider
Insurance ID Number
Submit