Moffat County Public Health COVID-19 VACCINE INTEREST FORM

Moffat County Public Health COVID-19 VACCINE INTEREST FORM

This form is for individuals who would like to express interest for COVID19 Vaccine clinics.
You will receive a call to sign up for a vaccine appointment as doses become available for your priority group. (per state guidance). Please complete the form below COMPLETELY. We are working as quickly as we can to get our community vaccinated.

*FILLING OUT THIS FORM DOES NOT CREATE AN APPOINTMENT NOR DOES IT GUARANTEE A VACCINE*
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Primary Residence
Employment Sector *
Which of the following describes you? (Select all that apply) *

Adult with a high risk medical condition (obesity, diabetes, chronic lung disease, heart disease, chronic kidney disease, cancer or immunocompromised) Interact directly with the public at work (such as grocery store workers, healthcare with direct patient care and school staff) 70 years of age or older None of these describe me
I affirm and certify that all of the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief? *

Yes No
Should be Empty:

You will receive a call to sign up for a vaccine appointment as doses become available for your priority group. (per state guidance). Please complete the form below COMPLETELY. We are working as quickly as we can to get our community vaccinated.