COVID-19 Vaccine Waitlist Form
Name
First Name
Last Name
Age
Gender
Male
Female
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a front liner or a first responder?
Yes
No
What kind or type of first responder are you?
Health care worker
Law enforcement
Firefighter
Other
Are you over the age of 60?
Yes
No
Are you a patient of a nursing home or long term care facility?
Yes
No
Would you like to be on the waiting list?
Yes
No
Do you need any assistance to get your vaccine?
Transportation
Language assistance
Wheel chair assistance
Other
Comments, suggestions, or special instructions
Your Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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