Vaccine Volunteers IL - DOSE 2 COVID Vaccine Scheduling Assistance

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THIS FORM IS FOR INDIVIDUALS WHO RECEIVED THEIR FIRST DOSE, AND ARE LOOKING FOR A SECOND DOSE COVID-19 VACCINE APPOINTMENT.

As featured on NBC (x2) and CBS. Endorsed by the office of State Senator Julie Morrison.

Submission of this form does not guarantee a COVID-19 vaccine appointment.

You should never be asked for any part of your SSN or any passwords. If you are, please immediately discontinue contact with the volunteer and report it to the contact information below.

While we strive to keep your information safe and will only intentionally share it among approved volunteers for the purposes of scheduling a COVID-19 vaccination appointment, we cannot guarantee privacy and security of your information. Vaccine Volunteers IL is not responsible for terms and policies set forth by third parties, including Google, our form provider.

Vaccine Volunteers IL was created by Avi Rubin, a high school student in Highland Park who has helped connect COVID-19 vaccine appointments to more than 400 individuals.

Our team: Avi, Jamie (JME), Erica, Tracy, Catherine, Susan

For form assistance, email VaccineVolunteersIL@gmail.com or text ‪(312) 210-0311‬

Email *

Whose information are you entering? *

My own

My parent

My spouse

My caregiver

Other:

YOUR First Name *

This field is for people submitting on behalf of others. If you are submitting for yourself, please fill this field out and the one below both with your first name.

First Name *

Last Name *

What county does the individual live in? *

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