COVID-19 Vaccine Interest Form
Please complete this form if you are interested in receiving a COVID-19 vaccine. When we reach your priority group and vaccine is available, Allegany County Health Department or UPMC Western Maryland will contact you by email or phone to schedule a vaccination appointment.
Completing this form does NOT make you an appointment to be vaccinated. It may take several weeks, or longer, until you are contacted to schedule an appointment because of limited vaccine supply.
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City or town
Email address (enter "none" if you have no email)
Do any of these apply?
I live in a group home or congregate setting
I am certified as having a developmental disability
None of these apply
Do you have one or more of the following health conditions: cancer, cardiomyopathies, chronic kidney disease, COPD, coronary artery disease, Down syndrome, heart failure, obesity (body mass index over 30), organ transplant, pregnancy, sickle cell disease, smoking, Type 2 diabetes?
Yes, I have one or more of these conditions.
No, I have none of these conditions.
I am employed in one of the following fields:
College or university
Daycare or nursery school
Education PreK-12th grade
Healthcare provider (licensed, registered, or certified)
Law enforcement, EMS, firefighter
U.S. Postal Service
Utilities (water, power, gas)
Veterinarians and support staff
None of the above
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This form was created inside of State of Maryland.