Saguache County Vaccination Interest Form
Saguache County Residents:
Please complete this form if you would like to be added to a list to receive information about vaccination opportunities and/or appointments as they become available. Your information will not be shared outside of public health.
Filling out this form will inform us of the number of people interested in receiving a vaccine in each phase. It does not guarantee a vaccine in any time frame. The pace at which we are able to provide vaccinations is dependent upon vaccine availability and evolving State and Federal guidance.
Only fill out this form ONCE PER PERSON.
Thank you for working with us to help keep our community safe and healthy.
If you listed a phone number, may we send you text messages?
To which work group or community role do you belong? (You may choose more than one if you like).
Age 70 or above
Age 50 and older
Agricultural and Food Industry Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)
Behavioral Health Worker
Care provider for Coloradans experiencing homelessness front line worker.
Child Care Worker
Clinical trial participant who received a placebo
Coroner and Funeral Worker
Correctional Officers (Jail or Prison Front Line Worker)
COVID-19 response personnel
Critical Infrastructure Worker (Public Works, IT & Communication)
Educators (Teachers, Faculty and Staff)
Essential Official from State Government Branch (Executive, Judicial, Legislative)
First Responders (EMS, Firefighters, Law Enforcement, Search and Rescue)
Food or Restaurant Front Line Worker
Grocery Front Line Worker
Higher-risk individual (obesity, diabetes, chronic lung disease, significant heart disease, chronic kidney disease, cancer, or are immunocompromised).
Higher Education Employees (Student-facing)
Human Services Front Line Worker
Journalist Front Line Worker
Manufacturing Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)
Public Health Front Line worker
Public Transportation and Specialized Transportation Staff
Public Utilities Front Line Worker (Unable to work from home with high levels of interaction with public or others in the workplace)
U.S. Postal Service Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)
General Public (Anyone age 16-59)
Under 16 years old
Have you received your first dose of the COVID-19 vaccine?
Where would you like to receive your vaccine? (You may choose more than one if you like).
Any Additional Comments:
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This form was created inside of Alamosa County.