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Vaccine Interest Form
Completing this form does NOT make you an appointment to get the vaccine.
You only need to complete the form once.
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* Indicates required question
Email
*
Your email
Full Name (First, Middle, Last)
*
Your answer
Phone Number
*
Your answer
Current Age (We are currently receiving Moderna, which is approved for those 18 and older)
Your answer
Phase 1a-c, 2a priority groups
If you received the COVID-19 vaccine from a different provider and want to remove your name from our contact list, you are able to edit your previous chosen priority group to Already vaccinated . . . . .
Priority Group
*
Already vaccinated at a different vaccine clinic
Aged 60 or older
licensed, registered and certified health care provider
Law enforcement and firefighters, EMS
Correctional health care staff and officers
Front line judiciary staff
Individual with intellectual and developmental disabilities
Education Teacher or Staff
daycare provider
Continuity of government
Public safety workers not covered in Phase 1A
Health care workers not covered in Phase 1A, including but not limited to lab services, public health, vaccine manufacturing and other health care professions
Food/agriculture production
critical manufacturing
U.S. Postal Service
public mass transit
grocery store employees
Veterinarians and support staff
Clergy and other essential support for houses of worship
Certain immunocompromised individuals who are currently receiving hospital-based treatment, including in hospital outpatient centers
Marylanders age 16 and older with underlying medical conditions that increase the risk for severe COVID-19 illness
Home bound individuals
Employer name/organization name
*
Your answer
County of Residence
*
Your answer
Preferred language
*
English
Spanish
Other:
If you can be at one of our clinics within 30 minutes you can be placed on a "quick call" list to be notified if there are last minute cancellations. Would you like to be placed on this list?
Yes
No
A copy of your responses will be emailed to the address you provided.
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