Sign-up for COVID 19 Vaccine for 75+
Individuals 75 and older can sign-up on this form or call the Franklin Senior Center at 508-520-4945 to receive the COVID-19 vaccine. Because both Pfizer and Moderna vaccine supply is severely limited, the vaccine is not guaranteed. This sign-up form is to see who wants the COVID 19 vaccine.
Sign in to Google to save your progress. Learn more
What an individual needs to know before receiving the vaccine.
The Vaccine is free.
Wear a mask that covers your nose and mouth.
You will get a vaccination card that tells you which COVID-19 vaccine you received, and when and where you received it. The card will remind you to return for a second dose.
The vaccination site will tell you when to come back for your second appointment.

Make sure you get both doses.
It's important that you get the same type of vaccine both times.
Go back to the same vaccination site to get the second dose.
Keep others safe.
The COVID-19 vaccine — while showing extremely positive results — is like every other vaccine in that none is ever 100% effective. To keep people safe you must continue wearing a mask, washing your hands, keeping your distance, and avoiding groups.

It will take time to get the COVID-19 vaccine rolled out and get everyone vaccinated.  
Are you 75+?
Clear selection
Do you want a vaccine if you are 75+?
Clear selection
Are you a Franklin resident?
Clear selection
What is your name?
What is your address?
What is your phone number?
What is your email address?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Town of Franklin.

Does this form look suspicious? Report

Google Forms