Vaccine Interest Form
Completing this form does NOT make you an appointment to get the vaccine.
You only need to complete the form once.  

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Email *
Full Name (First, Middle, Last) *
Phone Number *
Current Age (We are currently receiving Moderna, which is approved for those 18 and older)
Phase 1a-c, 2a priority groups
If you received the COVID-19 vaccine from a different provider and want to remove your name from our contact list, you are able to edit your previous chosen priority group  to Already vaccinated . . . . .
Priority Group *
Employer name/organization name *
County of Residence *
Preferred language *
If you can be at one of our clinics  within 30 minutes you can be placed on a "quick call" list to be notified if there are last minute cancellations. Would you like to be placed on this list?
A copy of your responses will be emailed to the address you provided.
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