COVID-19 Vaccine Enrollment Form
Please Register One Time ONLY- You will be contacted when an appointment is available.
Date of Birth
Hispanic or Latino
Not Hispanic or Latino
American Indian/Alaska Native
Native Hawiian/Pacific Islander
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Are you employed by any of the following types of patient-facing organizations: (hospital, home health, hospice, office that provides COVID-19 testing, congregate healthcare setting such as an adult daycare, physician office, dialysis center, outpatient healthcare, dental office, other healthcare, school district-nurse, correctional nurse or EMS)
Do you have any of the following high risk medical conditions? (Please select all that apply)
Chronic Kidney Disease
COPD (Chronic Obstructive Pulmonary Disease)
Chronic Heart Disease (such as congestive heart failure, coronary artery disease, or cardiomyopathy)
Sickle Cell Disease
Immunocompromised from Solid Organ Transplant
Severe Obesity (BMI >40kg/m2)
Intellectual and/or Developmental Disabilities such as Down Syndrome
None of the Above
Are you a:
Non-Patient facing Health Care Provider
Emergency Management and/or Public Works
Emergency Services Sector (law enforcement, fire and rescue services)
If selected other, please list your occupation
Are you available for a walk-in appointment within one hour if called by our staff?
Have you received the COVID-19 vaccination?
I consent to receive email notifications regarding COVID-19 vaccination availability and clinic opportunities based on my assigned tier group.
I consent to receive text message notifications regarding COVID-19 vaccination availability and clinic opportunities based on my assigned tier group. Message and data rates may apply.
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform