COVID-19 Vaccine Registration Form

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Are you interested in receiving the COVID-19 Vaccine?

SCHD is working closely with area partners to determine the best way to distribute the COVID-19 vaccine. The distribution schedule is based on vaccine availability, with guidance from the Missouri Department of Health and Human Services (MO DHSS) and the Center for Disease Control (CDC). SCHD will provide the COVID-19 vaccine based on a phased approach pre-determined by the State of Missouri. Individuals will be identified to receive the vaccine based on risk status and occupation.

Once the vaccine is made available for your group based on the current phase, SCHD will use your information from this survey to contact you with further instructions on how to schedule an appointment to receive your vaccination.

Per the guidance provided by the CDC, COVID-19 vaccinations will not be provided to those under the age 16.
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Name* This field is required.
First Name
Last Name
3
Birth Date* This field is required.
Date
Month
Day
Year
4
Age* This field is required.
5
Gender* This field is required.
Female
Male
6
Ethnicity* This field is required.
Hispanic/Latino
Non-Hispanic
Unknown
Refuse to answer
7
Race (check all that apply)* This field is required.
Black
White
Asian
American Indian/Alaska
Native Hawaiian/Other Pacific Islander
Unknown
Refuse to answer
8
Email* This field is required.no email please enter na@gmail.com
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
10
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Are you pregnant or trying to become pregnant?* This field is required.'
YESNO
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Do you have any chronic medical conditions* This field is required.
YESNO
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Do you have any underlying medical conditional conditions?* This field is required.Click all that apply
Diabetes
Hypertension
Severe Obesity
Cardiovascular Disease
Chronic Renal Disease
Immunosuppressive Condition - Organ Transplant
Autoimmune Condition
Disability (neurologic, neurodevelopmental, intellectual, physical, vision or hearing impairment)
Psychological/psychiatric Condition
Cancer
COPD (Chronic Obstructive Pulmonary Disease)
Sickle Cell Disease
14
Have you been diagnosed with COVID-19?* This field is required.
Yes
No
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What month/year were you released from contact tracing?* This field is required.Month/Year
April, 2020
May, 2020
June, 2020
July, 2020
August, 2020
September, 2020
October, 2020
November, 2020
December, 2020
January, 2021
February, 2021
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Have you ever had a serious reaction after any vaccination or injectable medication including a previous dose of COVID-19?* This field is required.
YESNO
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Have you ever had a severe allergic a reaction to something that required treatment with epinephrine or Epi Pen or for which you had to go to the hospital?* This field is required.
YESNO
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Who is your employer?* This field is required.Please list company name and phone number
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SignatureI hereby declare that all the given information are accurate
Clear
Should be Empty: