COVID-19 Phase 1A Vaccination Registration Form
If your organization is in the 1A prioritization list please complete this form to be listed on the vaccination scheduling list. You will be notified of the location, time and method.
Agency/Organization Name
Organization Type
Please Select
Home Health Workers
Hospice Workers
Emergency Medical Services Responders
Primary Care Providers
Dental Providers
Public Health Employees
Mobile Unit Practitioners
Federally-Qualified Health Center Providers
High-Risk Ancillary Health Care Staff Members
In-Patient Settings
Healthcare Staff in Congregate Living Settings
School Health Personnel
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you affiliated with a health care/hospital system?
Yes
No
How many staff under Phase 1A are interested in receiving the vaccine?
Of those interested, how many have pre-existing conditions?
Of those interested, how many are aged 65 or older?
Primary Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Register
Should be Empty: