COVID-19 Vaccine Event Registration Form
Name
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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12
13
14
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18
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20
21
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25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
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1975
1974
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1971
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1964
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1961
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1958
1957
1956
1955
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1952
1951
1950
1949
1948
1947
1946
1945
1944
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1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
Please Select
Female
Male
Prefer not to say
Marital Status
Please Select
Single
Married
Divorced
Widowed
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Email
example@example.com
Phone Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select your qualifying criteria
65 years old or older
55 - 64 with one or more of the following health conditions: cancer, chronic kidney disease, COPD, Down Syndrome, heart conditions, immunocompromised state from solid organ transplant, obesity, severe obesity, sickle cell disease, smoking, Type 2 diabetes mellitus
Dialysis providers and patients
First responders to serve as vaccinators
Ambulatory/outpatient providers and staff (behavioral health, urgent care, community care, dental)
Home agency patient and/or personnel
American Sign Language (ASL) and foreign language interpreters and Support Service Providers (SSPs)
Health-related support personnel (lab staff, mortuary staff who have contact with corpses, pharmacy staff)
Allied health student/resident/staff
Law enforcement and other first responders
State and local essential COVID emergency response personnel
Elections staff ahead of March elections
Teachers and any other K-12 or daycare support staff
Pregnant
Appointment Time
Submit
Should be Empty: