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Vaccine Availability Notification
NOTE* This is NOT registration for the COVID-19 Vaccination. This is a sign-up for notification when the vaccine becomes available to your assigned tier.
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First Name
*
Your answer
Last Name
*
Your answer
Birth-year (Ex. 1940, 1989, 2001)
*
Your answer
Street Address
Your answer
City
*
Your answer
Phone Number
*
Your answer
Email (Optional)
Your answer
Preferred Contact (Select all that apply)
Call
Text
Email
Mail
Do you have any medical conditions which put you at greater risk with COVID?
*
Yes
No
If Yes, what medical condition(s) have you been diagnosed with?
Your answer
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