Vaccination Sign Up Form (Phase 1B)
Must be a Lebanon County resident or employed in the county and one of the following:

• First responders (Fire and Law Enforcement)
• Correctional officers and other workers serving people in congregate care settings not included in Phase 1A
• Food and agricultural workers
• U.S. Postal Service workers
• Manufacturing workers
• Grocery store workers
• Education workers
• Clergy and other essential support for houses of worship
• Public transit workers
• Individuals caring for children or adults in early childhood and adult day programs

*These categories are general groups. For a more granular list of eligible positions please consult the DOH vaccine plan found here:
https://www.health.pa.gov/topics/Documents/Programs/Immunizations/PA%20Interim%20Vaccine%20Plan%20V.4.pdf

*Additional vaccine guidance can be found at the Department of Health's website here:
https://www.health.pa.gov/topics/disease/coronavirus/Pages/Vaccine.aspx
Email address *
Which workforce category best fits your occupation? *
If "All Other" selected above, please describe your service industry
Last Name *
First Name *
Birth Date *
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DD
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Cell Phone Number *
Phone Number Extension
Name of Employer, Company, or Agency *
Employment Verification Contact Name (HR, Supervisor, Etc.) - First and Last *
Employment Verification Contact Title or Position *
Employment Verification Contact Number (HR, Supervisor, Etc.) *
Employment Verification Contact Number (HR, Supervisor, Etc.) Extension
Have you tested positive for Covid-19 within the past 90 days? *
Scheduling and Appointments
Make sure that all your information is correct before submitting this form. After eligibility is validated we will be contacting you with specific scheduling availability and pertinent paperwork required in order to complete your vaccination.
A copy of your responses will be emailed to the address you provided.
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