COVID-19 Vaccine Pre-registration- Facilities
DISCLAIMER: Filling out this form does not guarantee your chances of getting the COVID-19 vaccine. Once we have more information, we will contact you personally. Thank you for your interest and stay safe.
First and last name of Contact Representative
Facility Type (LTC, SNF, Group Home, etc.)
Full Address of Facility
e.g. "1919 W North Ave, Milwaukee, WI 53206" "Homeless" if you are currently experiencing homelessness
Full phone number with area code. e.g. 414-374-0000
A copy of your responses will be emailed to the address you provided.
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