1b COVID-19 Vaccine PRE-REGISTRATION FORM

Thank you for expressing interest in receiving the COVID-19 vaccine. This form may be used by eligible members of the current vaccine distribution group as defined by the Centers for Disease Control (CDC).

I am a:*

Select most relevant category

Name*

First NameMiddle InitialLast Name

DATE OF BIRTH*

Date

AGE*

Gender (please select one)*

FemaleMaleNon-BinaryPrefer not to answer this question

PHONE NUMBER*

STREET ADDRESS*

Please note: a PO BOX will not be accepted

CITY*

STATE*

ZIP*

Email

example@example.com

WHAT IS YOUR RACIAL IDENTITY?*

IS YOUR ETHNIC HERITAGE HISPANIC OR LATIN-AMERICAN?*

YesNoPrefer Not to Answer

MORGAN COUNTY HEALTH DEPARTMENT CONTRAINDICATION CHECKLIST FOR COVID-19 VACCINATIONS 2020/2021