COVID-19 Vaccine Interest Form
Be sure to only fill out forms found on our website at Yadkincountync.gov. We will never ask you for information such as passwords, social security numbers, etc. If you or someone you know needs assistance filling out this form, please call: (336) 849-7910 and ask to speak with the Medical Clinic. For information on chronic conditions that can have an impact on you if you were to get COVID-19, please visit: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
First Name *
Last Name *
Email address:
Cell Phone number:
Enter your area code and number only (e.g.: 3365555555)
Home Phone number:
Enter your area code and number only (e.g.: 3365555555)
Are you any of the following:
Are you age of 75 years or older?
Choose this if you are 75 years or older regardless of your health status or living situation (that is, no chronic conditions are required to choose this).
Are you a healthcare worker or frontline essential worker 50 years of age or older?
The CDC defines frontline essential workers as first responders (e.g., firefighters and police officers), corrections officers, food and agricultural workers, U.S. Postal Service workers, manufacturing workers, grocery store workers, public transit workers, and those who work in the education sector (teachers and support staff members) as well as child care workers.
Are you a healthcare worker or frontline essential worker 49 years of age or younger?
The CDC defines frontline essential workers as first responders (e.g., firefighters and police officers), corrections officers, food and agricultural workers, U.S. Postal Service workers, manufacturing workers, grocery store workers, public transit workers, and those who work in the education sector (teachers and support staff members) as well as child care workers.
Are you between the age of 65-74 years?
Choose this if you are between 65-74 years of age regardless of your health status or living situation (that is, no chronic conditions are required to choose this).
Are you between the age of 16-64 years old with high-risk medical conditions that increase risk of severe disease from COVID-19 such as cancer, COPD, serious heart conditions, sickle cell disease, Type 2 diabetes, among others, regardless of living situation?
Are you someone who is (or signing up for someone who is) incarcerated or living in other close group living settings who is not already vaccinated due to age, medical condition or job function:
*Note, if you are signing up for someone who is incarcerated, be sure to contact the Yadkin County Medical Clinic at (336) 849-7910 and inform them of this.
Are you an essential worker not yet vaccinated?
The CDC defines these as workers in transportation and logistics, water and wastewater, food service, shelter and housing (e.g., construction), finance (e.g., bank tellers), information technology and communications, energy, legal, media, and public safety (e.g., engineers), and public health workers.
Are you a College or University Student?
Are you a K-12 student age 16 or over?
Younger children will only be vaccinated when the vaccine is approved for them.
If you did not choose any of the above but would still like to receive the vaccine, please confirm here.
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