1B COVID Vaccine Form
Please only fill out this form if you WILL take the vaccine when it is available to you. If you have any difficulty filling this form out please call (307) 367-2157. We are happy to help!!
* Required
First Name
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Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
Email
Your answer
What is your Date of birth
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MM
/
DD
/
YYYY
Age (as of today)
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Your answer
Have you tested positive (NOT ANTIBODY TESTING) for COVID-19 in the last 90 days?
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Yes
No
Please choose only one of the following categories:
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Fire, police, 911, correctional staff, search and rescue, support for ambulance, hospitals and DFS
>70 years of age or older.
National Guard and Air Guard members likely to be activated for response to the pandemic
Healthcare providers, behavioral health providers, and social workers.
K-12 Education (teachers and support staff)
Child care service providers
Public transit employees- community transportation buses
Grocery store, commercial meat processing, food supply chain, and food manufacturing employees
US Postal Service, delivery (UPS and Fed Ex) and lab specimen courier employees
Where do you prefer to receive your Vaccine?
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Pinedale
Marbleton
Are you willing to be on an "On call list"? (short notice as needed to fill open slots)
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Yes
No
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