COVID-19 Vaccine Event Registration Form

COVID-19 Vaccine Event Registration Form
Name
First NameLast Name
Birth Date
MonthDayYear
Gender
Marital Status
Race
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
CityState / Province
Postal / Zip Code
Please select your qualifying criteria
65 years old or older55 - 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 mellitusDialysis providers and patientsFirst responders to serve as vaccinatorsAmbulatory/outpatient providers and staff (behavioral health, urgent care, community care, dental)Home agency patient and/or personnelAmerican 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/staffLaw enforcement and other first respondersState and local essential COVID emergency response personnelElections staff ahead of March electionsTeachers and any other K-12 or daycare support staffPregnant
Appointment Time
Should be Empty: