COVID-19 Vaccine Registration Form
If you or a member of your family is part of the disabled community living in Monmouth County, fill out this form.

The ADA defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activity. This includes people who have a record of such an impairment, even if they do not currently have a disability. It also includes individuals who do not have a disability but are regarded as having a disability.

If you are a Monmouth County resident 65 or older, please fill out form at tinyurl.com/LD11seniors
Small business and restaurant owners, please fill out form at tinyurl.com/LD11Business

PLEASE ONLY FILL THIS FORM OUT ONCE. FILLING OUT MULTIPLE TIMES WILL RESULT IN REGISTRATION DELAYS.

Once filled out: look for an email from Senator Vin Gopal and Assembly Members Houghtaling and Downey on next steps.
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A copy of your responses will be emailed to the address you provided.
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