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)
Date of Birth:
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Address:
Phone Number:
Do you fall into any of these categories for Phase 1-B?
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Do you fall into any of these categories for Phase 1-C?
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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.
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