COVID-19 Vaccine Help Requested
Are you a vaccine-eligible person who has been unable to make their COVID-19 vaccination appointment? Do you know someone who is struggling with the technology to make their vaccination appointment? This is the form to request help from volunteers from the #VaxUpWestchester initiative of the Town of Greenburgh.

Please know that we are a group of volunteers working to help those eligible to make vaccination appointments who cannot do so on their own. This is not a guarantee of an appointment but we will try our best to help you.  

Please complete as much information below as is available.  Not all information is required.

The responses will be entered into our system and the person will receive a call from a volunteer within a few days.

This link can be shared, if needed.  https://forms.gle/CMauFiZLHM5iLMoV9

_VOLUNTEERS_: IF you have already completed the INTAKE FORM and SELECTED "Yes Please Add" to Team List, you _DO NOT NEED_ to fill out a help request.  Thank you!
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Name *
Legal first and  Last name
Phone Number *
Area Code and Number. Please enter in xxxxxxxxxx format. No spaces or dashes.
Email Address
If email is not available, please leave this field blank.  This is not required.
Other Info
Please feel free to provide other details here that may assist our volunteers.
(VUW/Town USE ONLY) - Submitted by or ADD TO TEAM Request:
IF YOU are requesting that this person be assigned to YOU, please put TEAM # - Your Name (SAMPLE: Team 11 - Alise).  If this can go to any volunteer, please leave blank!
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