Lafayette County Health Department COVID-19 Vaccine Sign-up
This does not guarantee you an appointment or confirm your request. Further communication will come as details are available to the Lafayette County Health Department
* Required
Email address
*
Your email
First name
*
Your answer
Last name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Lafayette County County of Residence
*
Your answer
Occupation
*
Paid Health Care Provider
Unpaid Health Care Provider/Volunteer
Emergency/Law Enforcement Personnel
Food Packaging/Distribution Workers
Teachers/School Staff
Local Government
Child Care Provider
Utilities/Public Works
Retired
Other
Name of Employer
*
Your answer
Do you have any underlying health conditions?
*
Yes
No
Are you currently on any other vaccine waitlists?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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