COVID-19 Vaccination Registration Form

Please provide the following information to complete the registration process.

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Required Fields

First name

Enter a valid first name

Last name

Enter a valid last name

Date of birth

Enter a valid date of birth

Email address

Enter a valid email address

Verify email address

Email addresses must match

Cell phone

Enter a valid phone number (ex: 555-555-5555)

Verify cell phone

Phone numbers must match

Address

City

State

ZIP

Please answer the following questions to complete the registration process.

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Required Fields

What is your ethnicity?

This question helps us better understand who we are reaching. Your answer does not affect your eligibility to receive the vaccine in any way.

Select an ethnicity

I prefer not to answer

What is your race?

This question helps us better understand who we are reaching. Your answer does not affect your eligibility to receive the vaccine in any way.

Select a race

I prefer not to answer

Do you have a medical condition that **puts you at increased risk** of severe illness from the virus that causes COVID-19?

Select all that apply. link:Visit the CDC's website to learn more.|https://www.cdc.gov|

I prefer not to answer

Do you have a medical condition that **might put you at increased risk** of severe illness from the virus that causes COVID-19?

Select all that apply. link:Visit the CDC's website to learn more.|https://www.cdc.gov|

I prefer not to answer

Do you have an occupation that the CDC recommends should be prioritized for COVID-19 vaccination?

link:Visit the CDC's website to learn more.|https://www.cdc.gov|

You're almost done! Please verify your contact information.

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We will use the email address or phone number you provide to contact you when it's time to schedule your vaccine appointment.

Warning: You won't be able to change your contact info after the form is submitted.

First name

Last name

Date of birth

Email address

Cell phone

Address

ReportingEthnicityQuestion

ReportingRaceQuestion

Do you have a medical condition that **puts you at increased risk** of severe illness from the virus that causes COVID-19?

ReportingMaybeIncreasedRiskQuestion

ReportingOccupationQuestion

Note that submitting this pre-registration form does not schedule a vaccination appointment. This submission adds you to a COVID-19 vaccine waitlist that will alert you when you can begin the scheduling process.

COVID-19 Vaccination Registration Form

Do you qualify for the COVID-19 vaccine per link: these guidelines|https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html|?