COVID-19 Phase 1C Vaccination Registration Form
The following people are considered eligible for vaccination in Phase 1C
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
County
City/Town
Phase 1C Group
Adults aged 40 to 64 with high-risk medical conditions
Other essential workers
Specify Essential Worker Type
Other
Only certain health departments currently have vaccine. Please select which health department you prefer to be contacted by for your vaccine appointment:
Columbus
Dooly
Crisp
Talbot
Chattahoochee
Marion
Taylor
Stewart
Clay
Quitman
Randolph
Schley
Macon
Harris
Webster
Sumter
Submit
Should be Empty: