Vaccination Sign Up Form (Phase 1A)
In order to quality for this phase of vaccination you must meet the following criteria:

•Must be an active and licensed medical provider (provide medical license number)

• Must be currently employed or an active volunteer with an organization that provides licensed emergency medical service to Lebanon County (EMS and QRS).

• Must have run a call and had patient contact within the last 45 days (PCR validation may be required).

*If you you do not meet the requirements of this phase of vaccinations you may be eligible for future vaccinations under phase 1B / 1C. Further information and availability information to be distributed after the completion of 1A recipients.

*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
Email address *
Agency / Organization affiliation *
Last Name *
First Name *
Birth Date *
MM
/
DD
/
YYYY
Cell Phone Number *
Email Address *
PA Medical License Number (EMT, EMR, PHRN, Etc.) - *Direct Support Personnel input "DSP" *
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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