COVID-19 Vaccine Notification Form
If you are a Charlton resident or an employee who works in Charlton and are interested in receiving the COVID-19 Vaccine, please complete this form so we can notify you when a clinic becomes available to you. You can fill out this form on behalf of someone else. If you are inquiring about several individuals, please fill out one form for each individual. Notifications will be sent by email.
The state is closely following a Vaccine Distribution Plan. The vaccine is being distributed in order of Priority identified in the plan. We will use the information gathered in this form to provide you updates on where and when you can receive the vaccine. More information on the COVID-19 vaccine is found at
This form was created by the Charlton Health Department.
Phone Number (optional)
If you are filling out this form on behalf of someone else, please enter your name and relationship to the person named above.
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