Starr Library - Rhinebeck Responds Vaccination Sign Up for Assistance
Thank you for contacting us to assist in signing you up for COVID-19 vaccination.  Please complete the information below and you will be contacted by a volunteer.

Si prefiere un formulario en español, siga las instrucciones de la tercera pregunta a continuación.
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Currently, New York State has restrictions on who is eligible for a vaccine.  The first restriction is age, so are you over 18?  If you answered "Yes" please continue filling out the form and click "Submit" at the bottom.
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If you answered No to the above (under 18), you must fit the criteria of eligible New Yorkers in Phase 1a and 1b.  Please review the list here   https://covid19vaccine.health.ny.gov/phased-distribution-vaccine#phase-1a---phase-1b                                 After reviewing the list, do you qualify as an eligible New Yorker?     If you answer "Yes" please continue filling out the form and click "Submit" at the bottom.  If you answer "No" you do not qualify for a vaccine under current New York State guidelines and we are not currently able to assist you (please close form and do not submit).
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Are you more comfortable completing this form in Spanish?  If so, click Yes below then insert your Name, Phone and Email address then click Submit at the bottom.  We will get back to you with a Spanish language form.  If you are comfortable with English, please continue.       ¿Se siente más cómodo completando este formulario en español? Si es así, haga clic en Sí a continuación, luego ingrese su nombre, teléfono y dirección de correo electrónico y luego haga clic en Enviar en la parte al fondo. Nos comunicaremos con usted con un formulario en español. Si se siente cómodo con el inglés, continúe.
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Name (First, Last) *
Address (Address, City, State, Zip Code)
Phone number
Email Address
Describe what steps, if any, you have already taken to sign up for a vaccination.
Will you need transportation to vaccine appointments?
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How did you find Starr Library - Rhinebeck Responds Vaccination Program
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Do you know anyone else who needs assistance registering for the vaccine?  If yes, please provide name and contact information.
Questions or Comments
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