COVID-19 Vaccine Sign-up

Name*
First Last
Birthdate*
MM
DD
YYYY
Phone Number*
Email
Address
Street Address City State ZIP Code
Are you 75 or older?*
- Yes
- No
Are you a healthcare worker or front line essential worker 50 years or older?*
- Yes
- No
The CDC defines frontline essential workers as first responders (e.g., firefighters and police officers), corrections officers, food and agricultural workers, U.S. Postal Service workers, manufacturing workers, grocery store workers, public transit workers, and those who work in the education sector (teachers and support staff members) as well as child care workers.
Are you a healthcare worker and front line essential worker of any age?*
- Yes
- No
The CDC defines frontline essential workers as first responders (e.g., firefighters and police officers), corrections officers, food and agricultural workers, U.S. Postal Service workers, manufacturing workers, grocery store workers, public transit workers, and those who work in the education sector (teachers and support staff members) as well as child care workers.
Are you between the ages of 65 and 74?*
- Yes
- No
Are you between the ages of 16 and 64 and have a high-risk medical condition such as cancer, COPD, serious heart conditions, sickle cell disease, Type 2 diabetes, among others?*
- Yes
- No
Do you live in a close group or congregate living setting?*
- Yes
- No
Are you an essential worker?*
- Yes
- No
The CDC defines these as workers in transportation and logistics, water and wastewater, food service, shelter and housing (e.g., construction), finance (e.g., bank tellers), information technology and communications, energy, legal, media, and public safety (e.g., engineers), and public health workers.
Are you a student over the age of 16?*
- Yes
- No
Email
This field is for validation purposes and should be left unchanged.