Ray County Health Department COVID-19 Vaccine Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The information you provide in this form will allow RCHD to contact you when you are eligible to be vaccinated. PLEASE NOTE: This does not guarantee you will receive vaccination from RCHD. This is NOT a registration or consent form for vaccination. Continue to be on the lookout for opportunities to be vaccinated through your doctor, another health care provider, a mass vaccination clinic, a retail pharmacy, or through your employer. RCHD is following the vaccine distribution guidelines provided by Missouri Department of Health and Senior Services.

Name *

Date of Birth *

YYYY

Address *

County of Residence *

Phone number *

Please select the category that applies to you: *

Patient-facing healthcare worker or Long-Term Care Facility staff

First Responders, emergency services, and public health infrastructure

Age 65 or older

Adult with the following conditions: cancer, chronic kidney disease, COPD, developmental disabilities, heart conditions, organ transplant, severe obesity (BMI >40kg/m2), pregnant, Sickle Cell Disease, or Diabetes Mellitus

Critical Infrastructure: education, childcare, energy sector, food production/processing facilities, veterinary services, transportation systems sector, or water and wastewater systems sector

Equity and Economic Recovery: chemical sector, commercial facilities sector, critical manufacturing sector, defense industrial base sector, financial services sector, food/agriculture sector, government personnel, higher education, disproportionately affected or homeless populations (populations at increased risk of acquiring or transmitting COVID-19)

Other (please describe below)

Other category, please describe:

Employer *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms