COVID 19 Vaccine Sign Up
Your answers to this form's questions assist us in determining what phase you fall into, assuring that you are vaccinated at the appropriate time as outlined by the CDC and the Arkansas Department of Health.
Please double check that all questions are answered correctly before submission. We will be in contact with you to schedule your time to receive the vaccine.
Phase 1-B is estimated to begin in February.
Phase 1-C is estimated to begin in April.
Phase timelines and priority groups may vary based on available vaccine supply and medical need.
Name: (First and Last)
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Address:
Your answer
Phone Number:
Your answer
Do you fall into any of these categories for Phase 1-B?
70 Years Old or Older
Teacher or School Staff
Food/Agricultural Worker
Manufacturing Worker
Grocery Store Worker
Public Transit Worker
Child Care Worker
U.S. Postal Service Worker
Essential Government Worker
No, I do not fall into any of these categories
Clear selection
Do you fall into any of these categories for Phase 1-C?
65 Years Old or Older
16-64 Years Old with High Risk Medical Condition
Transportation and Logistics Worker
Water and Wastewater Worker
Food Service Worker
Shelter and Housing Worker
Finance Worker
IT and Communication Worker
Energy Worker
Media Worker
Public Safety/Health Worker
No, I do not fall into any of these categories
Clear selection
ATTENTION: The link below is to the Vaccine Consent Form. If you are able, please follow the link and print the form, but DO NOT FORGET TO SUBMIT THIS SURVEY. Please fill out the consent form down to the signature line and bring to your scheduled vaccination time.
https://drive.google.com/file/d/1ScTu2i3VdjqO5iZ53p2Q13wma5Co3h7v/view?usp=sharing
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