Childcare COVID-19 Vaccine Interest Form

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Childcare COVID-19 Vaccine Interest Form

If you are a formal or informal childcare provider in need of a self-report form, requesting a COVID-19 Vaccine appointment, or inquiring about your eligibility, please complete the following form and a member of the First 5 Yolo team or a team member from one of First 5's partner agencies will get back to you if spaces become available. Thank you!

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* Indicates required question

Are you hoping to schedule a COVID-19 vaccine appointment? *

Yes (If yes, all questions in Sections 1 and 2 must be answered)

No, I have another question/request. (Please complete Section 1: Contact Information and proceed to Section 3)

No, I already have an appointment

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