COVID Vaccine Sign-Up for Homebound San Joaquin County Residents

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This form is intended for homebound San Joaquin County residents to sign up for the in-home COVID vaccination contact list. If needed, a third party may fill out this form on the resident's behalf.

In order to qualify for in-home COVID vaccination an individual must be a San Joaquin County resident AND homebound.

Homebound is defined as someone who needs the help of another person or medical equipment such as crutches, a walker, or a wheelchair to leave their home, or their doctor believes that their health or illness could get worse if they leave their home, AND it is difficult for them to leave their home and they typically cannot do so.

Once the survey is completed, a member of the Public Health vaccination team will call to schedule an appointment for in-home COVID vaccination.

This survey is only for homebound individuals that meet the qualifications listed above. If the qualifications are not met, please do not continue with the survey. *

I attest that the above qualifications are met for in-home COVID vaccination. I certify that I am at least 18 years of age, or authorized to make medical decisions on behalf of the person named below. I certify that, to the best of my knowledge, the information submitted in this application is true and accurate. I understand that the information I provide here will be used to determine eligibility for receiving in-home COVID-19 vaccination. I give my consent to share my information that I provide here as needed with a licensed healthcare provider administering the vaccine, the California Department of Public Health and its contractors, and local health jurisdictions to provide me with COVID-19 vaccination services. I attest to the accuracy of the information provided and understand that falsifying information regarding eligibility could result in the delay of receiving a vaccine.

Required

First Name *

Last Name *

Date of Birth *

YYYY

Street Address *

City *

Zip Code *

Phone Number *

Contact Person (if not homebound person)

Preferred Language

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