COVID-19 Vaccination Notification

If you are interested in getting the COVID-19 vaccination, please complete the following form.

Once the form is submitted and depending on your criteria for receiving the COVID-19 vaccination, we will contact you and schedule you for an appointment using the information on this form when vaccine becomes available. Please complete only one response for each person.

First and Last Name *

Date of Birth

YYYY

Current Age

Contact Phone Number (with area code)

Which of the following categories do you meet?

Age 60 and older

Child care workers in licensed childcare programs, teachers (full-time and substitution) and other support school staff Pre-K -12

People 16-59 with 2 or more high risk conditions (defined as patients who are currently receiving treatment or have received treatment within the last month for cancer), chronic kidney disease, COPD, diabetes mellitus (types 1 and 2), Down syndrome, specific heart conditions (heart failure, cardiomyopathies or coronary heart diseases and sever valvular/congenital heart disease), obesity (BMI>30kg), pregnancy, sickle cell disease, solid organ transplant and people with disabilities who require direct care in their home, and people with disabilities that prevent them from wearing masks.

Frontline essential workers in grocery and agriculture: Prioritizing current workers who cannot maintain physical distance from others at their place of employment, who work in close contact with many people, especially indoors and in places with poor ventilation including meatpacking workers; grocery store workers; and agricultural processing workers.

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