COVID-19 Vaccination for People 75 Years and Older | Waiting List
Thank you for your interest in helping take the first steps out of the COVID-19 pandemic.  
 
As we receive confirmation of new shipments of vaccine doses we will call individuals from this list on a first-come first-serve basis.   Completing this form is NOT a guarantee that you will receive an appointment as there is tremendous demand and very limited supply of vaccine.
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Last Name *
First Name *
Year of Birth *
You must be 75 years or older to receive the vaccine. If you were born after 1946 then you do not qualify for this round of vaccines. You must present a form of ID to be given the vaccine.
Home Phone Number
Cell Phone Number *
Address *
You must live in either Franklin County, Colbert County, or the city of Vina.
Email Address (if you have one)
Alternate Email Address
I have previously received a COVID-19 vaccine. *
I have been tested for COVID-19 in the past two weeks. *
I have had a positive diagnosis of COVID-19 at any time. *
I am interested in being called on short notice if a work-in appointment is available. *
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