COVID-19 Vaccine Interest Form for Individuals

COVID-19 Vaccine Interest Form for Individuals
Please provide contact information to receive notification/update on the availability of the COVID-19 vaccine. By providing the following information you are assisting The County in vaccination planning efforts.
Contact Information
Name
First NameLast Name
Birth Date
MonthDayYear
Gender
FemaleMaleN/A
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Eligibility
Please select only ONE option that suits your condition
Phase 1A
Phase 1A generally covers individuals directly delivering health care and those living in institutional settings. Eligible occupations are listed in the dropdown above. Select the first option presented that applies to you; if none apply continue to the next question.
Phase 1B
Phase 1B generally covers "Frontline Essential Workers" and individuals 65-74. Review the choices in the dropdown above and select any option that applies to you, otherwise proceed to the next question.
Phase 1C
Phase 1C generally covers "Other Essential Workers." Review the choices in the dropdown above and select any option that applies to you.
Should be Empty:

Contact Information