Vaccination Sign Up Form (Phase 1C)
Must be a Lebanon County resident or employed in the county and one of the following:

Essential workers in these sectors:
• Transportation and logistics
• Water and wastewater
• Food service
• Housing construction
• Finance, including bank tellers
• Information technology
• Communications
• Energy, including nuclear reactors
• Legal services
• Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff
• Media
• Public safety
• Public health workers
Email address *
Which workforce category best fits your occupation? *
If "All Other" selected above, please describe your service industry
Last Name *
First Name *
Birth Date *
MM
/
DD
/
YYYY
Cell Phone Number *
Phone Number Extension
Name of Employer, Company, or Agency *
Employment Verification Contact Name (HR, Supervisor, Etc.) - First and Last *
Employment Verification Contact Title or Position *
Employment Verification Contact Number (HR, Supervisor, Etc.) *
Employment Verification Contact Number (HR, Supervisor, Etc.) Extension
Have you tested positive for Covid-19 within the past 90 days? *
Scheduling and Appointments
Make sure that all your information is correct before submitting this form. After eligibility is validated we will be contacting you with specific scheduling availability and pertinent paperwork required in order to complete your vaccination.
A copy of your responses will be emailed to the address you provided.
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