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CCACC At-Home Rapid Test Kits Pre-register 新冠病毒居家試劑預先登記表
Please fill out the form below to reserve your kits, and contact us at 240-393-5950 to make an appointment for pick up. 請填寫表格，並致電240-393-5950 預約領取時間。
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First Name 名
*
Your answer
Last Name 姓
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Your answer
Email 電郵
Your answer
Phone number 電話
Your answer
Zipcode 郵政編碼
Your answer
Race 種族
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Asian 亞太裔
African American
White
American Indian or Alaska Native
Native Hawaiian and Other Pacific Islander
Some other Race
Other:
Occupation 職業
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Childcare provider 育兒工作者
Construction worker 建築業
Grocery store or food service worker 賣場或餐飲業員工
Manufacturer worker 製造業
Healthcare worker 醫療業
Education worker 教育業
Unemployed 無職業
Student 學生
Other:
Do you speak 請問您能說下列幾種語言
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English 英文
Chinese 中文
Spanish 西文
French 法文
Other:
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