If you are eligible to receive the COVID-19 vaccine, please state which of the criteria you meet (for example "cancer," "current or former smoker," "law enforcement" or "teacher"). View eligibility requirements here: https://ldh.la.gov/index.cfm/page/4137
First Name *
Last Name *
Date of Birth *
Telephone Number *
A copy of your responses will be emailed to the address you provided.