Vaccine Clinic Sign Up Form
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Name *
Email *
Address (Street, City, ZIP) *
Are you a resident of Adams County and have proof? (i.e. utility bill, signed lease, pay stub, etc.)
Phone number
Do you identify as a BIPOC person (Black, Indigenous, Person of Color? *
Which community do you identify yourself as a member of?
Clear selection
How many members of your household will need an appointment for a vaccine?
Clear selection
Are all household members seeking a vaccination older than 12 years of age?
Are you scheduling this appointment for a child who is aged 5 to 12 years of age? Please note the Pfizer vaccine is the only one available for this age group.
Which vaccine do you prefer?
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