COVID-19 Vaccine Interest Form for People with Pre-Existing Conditions that put them at greater risk (under age 65)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is NOT registration for COVID-19 vaccination. It is a vaccine interest and contact information form. Please complete this form so the Health Department can contact you when we have more information about the vaccine registration process for your group. Please complete a separate form for each person who is interested in receiving the vaccine and is in this category.

Name *

Street Address

City/Town *

Zip Code *

Phone Number

Email *

Do you drive or can someone else drive you to get a COVID-19 vaccination?

Yes

Other:

Clear selection

Could you register for vaccination online or could someone else help you register for vaccination online?

Yes

Other:

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of State of Maryland. Report Abuse

Forms