Costilla County Public Health COVID-19 Vaccination Interest Form

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Costilla County Residents:
Please complete this form if you would like to be added to a list to receive information about vaccination opportunities and/or appointments as they become available. Your information will not be shared outside of public health.

Filling out this form will inform us of the number of people interested in receiving a vaccine in each phase. It does not guarantee a vaccine in any time frame. The pace at which we are able to provide vaccinations is dependent upon vaccine availability and evolving State and Federal guidance.

Please only register using this form once per person.

Thank you for working with us to help keep our community safe and healthy.

First Name *

Last Name *

Email address

Phone number

If you listed a phone number, may we send you text messages?

Yes

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To which work group or community role do you belong?

Agricultural and Food Industry Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)

Child Care Worker

Clinical trail participant who received a placebo

Construction worker

Coroner and Funeral Worker

Correctional Officers (Jail or Prison Front Line Worker)

COVID-19 response personnel

Critical Infrastructure Worker (Public Works, IT & Communication)

Educators (Teachers, Faculty and Staff)

Essential Official from State Government Branch (Executive, Judicial, Legislative)

Essential Worker of Local Government

First Responders (EMS, Firefighters, Law Enforcement)

Grocery Front Line Worker

Manufacturing Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)

Public Utilities Front Line Worker (Unable to work from home with high levels of interaction with public or others in the workplace)

U.S. Postal Service Front Line Worker (Unable to work from home with high levels of interaction with the public or others in the workplace)

Veterinarian

Behavioral Health worker

General Public

Under 18 years old

Other:

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Have you received your first dose of the COVID-19 vaccine?

Yes

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Submit

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