COVID-19 Pre-Registration Form
This form serves as a means for residents of all ages from Cumberland to pre-register for a COVID-19 vaccination. Filling out this form does not mean that you have been registered for an appointment. You will be contacted when doses are available in accordance with state guidelines.
PLEASE NOTE: The State of RI is currently supplying each City and Town with an extremely limited number of doses each week, and the Town of Cumberland has no control over this process. It may be several weeks or more before you are contacted to schedule your vaccination. The State may also change this procedure in the future, and we will update our website accordingly.
Full Name (First, Middle Initial, Last)
Date of Birth
75 and Older
Home Address (Must be a Cumberland Resident)
Primary Phone Number
Secondary Phone Number
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