COVID-19 Vaccine Interest Form

COVID-19 Vaccine Interest Form

Please provide the following information if you are interested in receiving the vaccine. We will notify you as vaccine clinics are scheduled and which categories are eligible to receive the vaccine as we move through local process.
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email - if you do not have an e-mail, please enter covid19@elkocountynv.net *
example@example.com
Address - not required, but helpful for to plan clinics especially in outlying areas.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
GENERAL POPULATION: *

Age 70+ Age 65-69 Age 18-64 with underlying health conditions, an individual with disabilities, or experiencing homelessness Healthy Adult Age 16 -64
FRONTLINE/ESSENTIAL WORKFORCE (Please choose one category) *

PUBLIC SAFETY & SECURITY FRONTLINE COMMUNITY SUPPORT FRONTLINE SUPPLY CHAIN & LOGISTICS FRONTLINE COMMERCE & SERVICE INDUSTRIES FRONTLINE INFRASTRUCTURE OTHER N/A
If you're unsure which category is most appropriate, please review the prioritization and and eligibility information here.
Should be Empty: