Maria Parham COVID-19 Vaccine Standby Wait List
Current Covid-19 vaccines come in multi-dose vials. Although vaccination slots are matched to available doses, cancelations may leave a few doses left at the end of a clinic. If you would like to be on the waitlist AND can quickly and safely be at the Maria Parham Clinic within 30 minutes of notification, please complete the questions below.

We are distributing the COVID-19 vaccines in accordance with prioritization guidance from the Centers for Disease Control and Prevention, the federal government, and our state. For more information please visit https://www.mariaparham.com/coronavirus-covid-19-vaccine-information.

Please also complete the CVMS questionnaire at https://immunize.nc.gov/providers/ncip/training/CVMS%20Recipient%20Registration%20Form.v5_01_25_2021.pdf
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Email address *
Today's Date *
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First Name *
Last Name *
Date of Birth *
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Are you a healthcare worker or emergency responder? *
Are you working in an essential frontline industry? *
If you are an essential frontline worker, please enter the name of your employer
Phone number *
Do you have another phone number if we can't reach you with the first? If so, please list.
Can you get to the Maria Parham Clinic safely within 30 minutes of notification? *
Thank you!
Thank you for your interest. Your information will be added to a list of individuals who would like to be contacted in the event of unused doses at the end of a Covid vaccination clinic.

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