BACOOR CITY
COVID ELECTRONIC IMMUNIZATION RECORD
REGISTRATION
LIGTAS BACOOR
This page is for the registration of 5-17 yrs old. Please click
here
to go back to adult registrations
First Name:
*
Last Name:
*
Middle Name:
Suffix:
Civil Status
*
Gender:
*
Birth Date:
*
June 2017
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31
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27
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Jan
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Nov
Dec
Today
Clear
Cellular
*
Land Line
Email:
Address
Room #:
Floor #:
Building #:
*
Street Name
*
Photo (2x2)
*
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Barangay
*
Town | City
*
Province
*
Region
*
Others
Ethnicity
Religion
Attainment
ALLERGIES
Drug Allergy
Insect Allergy
Mold Allergy
Pollen Allergy
Food Allergy
Latex Allergy
Pet Allergy
Parent | Guardian
First Name:
*
Last Name:
*
Middle Name:
Category
*
Category ID
ID #
Disability Card
With Comorbidity
*
Invalid value
COMORBIDITY
Hypertension
Kidney Disease
Bronchial Asthma
Cancer
HeartDiesase
Diabetes Mellitus
Immunodeficiency
Others
HISTORY
I am pregnant
I have been COVID diagnosed
Diagnostic Date:
June 2022
Sun
Mon
Tue
Wed
Thu
Fri
Sat
22
29
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31
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23
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24
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25
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25
26
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30
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27
3
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5
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9
Jan
Feb
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May
Jun
Jul
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Sep
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Nov
Dec
Today
Clear
COVID Class.:
I hereby voluntarily submit my information and that I authorise the City of BACOOR to utilize such in concern with the COVID 19 efforts. In addition, I have read and understood the privacy policy as stated in the
conditions of use
.
SUBMIT
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