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Cooke County COVID-19 Vaccine Sign-up
Cooke County COVID-19 Vaccine Sign-up
Submit this form to get on the list to receive a COVID vaccination once they become available. You MUST submit a separate form for each person requesting a vaccination.  Fields marked with a red asterisk are required. You will not be able to submit the form until all required fields are filled. You can't edit your answers after you submit the form.
17Questions
Cooke County Coronavirus Vaccination Request Form
  • 1
    Please visit the DSHS website to find vaccine providers near your location.
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  • 2
    To ensure safety and full treatment, we must remain consistent with the brand of vaccine each individual receives.
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  • 3
    To ensure safety and full treatment, we must remain consistent with the brand of vaccine each individual receives.
    • Pfizer
    • Moderna
    • Other
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  • 4
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  • 5
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Puerto Rico
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 6

    Cooke County Emergency Management requires information to contact you about the next steps in the registration process, clinic times, and locations.
    Double-check the information in the next section because if it is incorrect we will not be able to reach you about vaccination availability.

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  • 7
    Please enter a cell phone number so that we may send you text message notifications about the next steps in the registration process. To keep everything orderly, we will only be sending text message notifications to these phone numbers, so please ensure your information is correct. If submitting the form for several different people, you MAY use the same phone number for each person if necessary.
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  • 8
    Please enter an email address that you check every day so that we may email you about the next steps in the registration process. If submitting the form for several different people, you MAY use the same email address for each person, if necessary.
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  • 9

    The information in the next section determines if you fall into any of the priority groups for vaccination. It also helps us to know who is getting vaccinated and who still needs to be vaccinated.

    All required fields give you the option to select refuse to answer as a choice; however, that may impact our ability to determine your eligibility. Gender, Race, and Ethnicity, however, are required for reporting vaccines administered.

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  • 10
    Pick a Date
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  • 11
    These fields are required for reporting vaccines administered.
    • Male
    • Female
    • Non-binary
    • Refuse to Answer
    • White
    • Black
    • American Indian or Alaska Native
    • Asian
    • Native Hawaiian or Other Pacific Islander
    • Other/Mixed
    • Refuse to Answer
    • Non Hispanic/Latino
    • Hispanic/Latino
    • Refuse to Answer
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  • 12
    In Phase 1A front-line healthcare workers or residents of a long-term care facility are eligible to receive the vaccine. If you do not know if you meet eligibility, refer to the information here.
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  • 13
    If you are in Phase 1B, you may also be eligible to get the COVID-19 vaccine, depending on availability and the vaccine provider. Vaccine supply remains limited, but more vaccine doses will be delivered to providers each week. If you do not know if you meet eligibility, refer to the information here.
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  • 14

    We are only accepting registrations from people who fall into category 1A or 1B at this time. It is urgent that we get vaccines to the most at-risk populations right now. Please check back later to see if this has changed.

    If you need to change your answers, click the "Previous" button below.

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  • 15
    An underlying condition is a health condition that you have that makes you more likely to get sick. In most cases, it is a condition for which you receive ongoing treatment. Underlying conditions also make you more likely to get severely ill if you get COVID-19. Underlying conditions typically require routine medical visits so the condition can be monitored by a healthcare provider and/or treated with one or more. Adults of any age with the following conditions are at increased risk of severe illness from the virus that causes COVID-19: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down Syndrome, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies, Immunocompromised state (weakened immune system) from solid organ transplant, Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2), Severe Obesity (BMI ≥ 40 kg/m2)Pregnancy, Sickle cell disease, Smoking, Type 2 diabetes mellitus COVID-19 is a new disease. Currently, there is limited data and information about the impact of many underlying medical conditions on the risk of severe illness from COVID-19. Based on what we know at this time, adults of any age with the following conditions might be at an increased risk for severe illness from the virus that causes COVID-19: Asthma (moderate-to-severe),Cerebrovascular disease (affects blood vessels and blood supply to the brain), Cystic fibrosis,Hypertension or high blood pressure,Immunocompromised state (weakened immune system) from blood or bone marrow transplant,immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines, Neurologic conditions such as dementia, Liver disease, Overweight (BMI > 25 kg/m2, but < 30 kg/m2),Pulmonary fibrosis (having damaged or scarred lung tissues), Thalassemia (a type of blood disorder), Type 1 diabetes mellitus
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  • 16
    Review submission of information so that we may have accurate data.
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  • 17
    Confirm today's date for an accurate timeline of applicants.
    Pick a Date
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  • 18
    Confirmation code. Keep this code by writing it down or taking a picture of it with your phone. We will ask for this as a security identifier if you decide you need to be taken off of the waitlist for any reason.
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