Silver Thread Public Health District Covid-19 Vaccination Sign-Up Form
Thank you for your interest in receiving the COVID-19 Vaccine! We are collecting this information so that we can efficiently and equitably administer the limited vaccine doses that we are receiving. Details on who is eligible during each phase of the vaccine roll out can be found here:

Signing up here will enter your information into our system and you will receive a phone call as soon as we have an appointment available for your group. Please press submit at the end of the survey and your information will be recorded in our system.

While filling out this form will inform us of the number of people interested in receiving a vaccine in each phase, it does not guarantee a vaccine in any timeframe. When your time comes in the phases, you will be notified via phone or email to schedule an appointment for both doses of the vaccine 28 days apart. Please only register using this form once per person.

We currently have the Moderna Vaccine which is approved for adults over 18 years old. Each person 18 years and older in your household who is interested in receiving the vaccine should register as a separate entry. We encourage families to register their children under 18 as well, should a time come for a vaccine for younger age groups. However, there is no available information on when or if that may occur.

Thank you for working with us to help keep our community safe and healthy,
Your Silver Thread Public Health Team
First and Last Name *
Date of birth (MM/DD/YYYY) *
Age *
Gender *
Phone Number (xxx-xxx-xxxx) *
E-mail (If you do not have an E-mail please put N/A) *
Mailing Address *
Street Address *
City *
County of Residence *
State *
Zip Code *
Race/Ethnicity (check all that apply)
To which vaccine group do you belong? Please select ONE. If you belong to multiple groups, please select the FIRST group in the list below that you belong to. *
Have you received your first dose of the Covid-19 Vaccine? *
Is there any additional information you would like us to know about you?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy