Vaccine Interest Form - Hunt County
This form is to express your interest in receiving the COVID-19 vaccine in Hunt County.
Please make sure the information you enter is correct. You will not be able to change the information after you hit submit. Once submitted you will see a confirmation page for your form submission.
Complete the form for each person interested in receiving the vaccine, however, do not sign up the same person more than once.
Please know that completing this form does not guarantee an appointment to receive the vaccine. Any appointment will be confirmed later via email or phone.
* Required
Email address
*
Your email
Confirm Email
*
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Phone #
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
2 Digit State Code, example: TX, LA, OK
Your answer
Zip Code
*
Your answer
Are you over 65 years of age?
*
Yes
No
Date of Birth
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MM
/
DD
/
YYYY
Are part of the Phase 1A Vaccine Group?
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Phase 1A definition is located here:
https://www.dshs.texas.gov/coronavirus/immunize/vaccine/EVAP-Phase1A.pdf
Yes
No
Are you part of the Phase 1B Vaccine Group?
*
Phase 1B definition is located here:
https://www.dshs.texas.gov/coronavirus/immunize/vaccine/EVAP-Phase1B.pdf
Yes
No
Are you part of the eligible school and child care worker vaccine group?
*
See the definition of this vaccine eligible group here:
https://dshs.state.tx.us/immunize/covid19/HHSDirectiveforCertainEducationalandChildCareWorkers.pdf
Yes
No
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