COVID-19 Vaccine Interest Form for Essential Workers

COVID-19 Vaccine Interest Form

Essential Workers
Vernon County Health Department staff are currently working on identifying those that would like to receive the COVID-19 vaccine. We are currently working with health care workers, long term care staff/residents, police and fire personnel and those 65 years or older. Once the state gives us approval to move to the next group, which may include essential workers, we will start contacting those interested in receiving vaccine. More information to come on where and when you will be able to receive the vaccine. This is just the first step in identifying those that qualify
Are you 65 years or older and retired? *

Yes (STOP do not fill out this form) No
If you are 65 and older AND retired or have chronic health conditions AND not working, please use this link to pre-register for the vaccine:

https://hipaa.jotform.com/210124014290134
Name *

First Name Last Name
Email *
example@example.com
Date of Birth *

Month Day Year
Date
Phone Number (daytime) *
Please enter a valid phone number.
Phone Number (Evening)
Please enter a valid phone number.
City of Residence: *
Please select if you belong to one of the groups listed below: *
Employer *
Have you had COVID-19 within the past 90 days? *

Yes No
Do you have chronic health conditions? *

Yes No
List any food, medication or vaccine allergies:
Please verify that you are human *
Should be Empty: