Covid-19 Vaccination Pre-Registration Form
Please fill out this form if you are a New Milford resident age 65 or older.
If you have any questions regarding this form, please call the Senior Center at 860-355-6075.

All responses to this online pre-registration form will be kept CONFIDENTIAL and will only be used by the New Milford Health Department and Senior Center to communicate important updates regarding COVID-19 Vaccinations when available.

For a printable version of this form, click here: http://www.newmilford.org/filestorage/7526/18320/Covid-19_Vaccine_Reg_Form.pdf
Please select all of the following applicable Factors *
Required
Name (First and Last) *
Date of Birth *
MM
/
DD
/
YYYY
Residential Address
Street *
City, State, Zip Code *
Mailing Address
If different than your Residential Address
Street
City, State, Zip Code
Primary Phone Number *
Cell Phone (If different from your primary phone number)
Email Address - This is MANDATORY. The CDC requires each registrant provide their own individual email address. Shared accounts will not work for this purpose. *
Special Medical Attention
To better serve our community, we ask that you provide the following information
If there is anyone in the household that requires special medical attention in case of a power outage. *
If you answered "Yes" to the above question, please elaborate on what special medical attention is required? (ex. Oxygen, Dialysis Machine, etc.)
Submit
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