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
* Required
Email address
*
Your email
Which workforce category best fits your occupation?
*
Choose
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
Media
Public safety
Public health workers
All Other (Please Specify Below)
If "All Other" selected above, please describe your service industry
Your answer
Last Name
*
Your answer
First Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Cell Phone Number
*
Your answer
Phone Number Extension
Your answer
Name of Employer, Company, or Agency
*
Your answer
Employment Verification Contact Name (HR, Supervisor, Etc.) - First and Last
*
Your answer
Employment Verification Contact Title or Position
*
Your answer
Employment Verification Contact Number (HR, Supervisor, Etc.)
*
Your answer
Employment Verification Contact Number (HR, Supervisor, Etc.) Extension
Your answer
Have you tested positive for Covid-19 within the past 90 days?
*
Yes
No
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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