Hometown Pharmacy COVID-19 Waitlist

*****This is for the Algoma Hometown Pharmacy******
A new submission needs to be completed for each individual family member. Currently the vaccine we have on hand is only approved for ages 18 and older. Please make sure to fill out the entire form until you get to the last page that says Thank You! You should also receive an email confirmation from Jotform.
Name*
First NameLast Name
Birthdate*
MonthDayYear
Date
Cell Phone Number*
Area CodePhone Number
Email
example@example.com
Are you one of the following*
Healthcare WorkerAge 75 and olderFrontline Essential Worker (first responder, education, grocery, meat processing, manufacturing, postal service) - not all inclusive list **Please provide details below**Age 65 - 74Age 16-64 with high risk medical condition **please provide details below**Other
Please provide details: Which high risk medical condition do you have or where are you employed as an essential worker?
Should be Empty: