COVID-19 Vaccination Eligibility Certification Form

Thank you for the information you have provided. Based on your answers, you are eligible for {finalTier} under the COVID-19 Vaccination Distribution Plan.

For vaccine eligibility, you will need to provide us with all the information requested in this form (name, address, phone, email). You will be contacted by our representative once the vaccine is available for you to receive. 

Please note that the information collected in this form is solely used for the purpose of COVID-19 vaccination efforts and to determine the eligibility of the vaccine plan administration. We will never sell or share your information to any third party.

Thank you for the information you have provided. Based on your answers, you will be eligible for COVID-19 vaccine once it is offered to all people your age who do not have high-risk health conditions.

For vaccine eligibility, you will need to provide us with all the information requested in this form (name, address, phone, email). You will be contacted by our representative once the vaccine is available for you to receive. 

Please note that the information collected in this form is solely used for the purpose of COVID-19 vaccination efforts and to determine the eligibility of the vaccine plan administration. We will never sell or share your information to any third party.

Thank you for the information you have provided. Currently, there is no approved COVID-19 vaccine for children.

For notification for updates about vaccine eligibility, you will need to provide us with all the information requested in this form (name, address, phone, email). You will be contacted by our representative once the vaccine is available for you to receive. 

Please note that the information collected in this form is solely used for the purpose of COVID-19 vaccination efforts and to determine the eligibility of the vaccine plan administration. We will never sell or share your information to any third party.