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.
First Name *
Last Name *
Email address
Phone number
If you listed a phone number, may we send you text messages?
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To which work group or community role do you belong? (You may choose more than one if you like). *
Have you received your first dose of the COVID-19 vaccine?
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Where would you like to receive your vaccine? (You may choose more than one if you like).
Any Additional Comments:
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