COVID-19 Vaccination Registration Support

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Eligible Tyngsborough Residents should use this form to request assistance scheduling their COVID-19 vaccine. Utilizing the contact information provided, staff from the Council on Aging will contact you to help you schedule your vaccine. Please provide all information requested.

Individuals completing this form for eligible residents should indicate if they wish to be contacted directly or if staff should contact the eligible resident.

Please call the Council on Aging for more support by dialing 978-649-9211.

Email *

Name (First & Last) *

Are you completing this form for yourself or on behalf of an eligible resident? *

Completing the Form for Myself

Completing the Form for Eligible Resident

Are you eligible under the current phased approach? *

Yes

How do you wish to be contacted? *

Telephone

Please provide the contact information. You may list a phone number and email or just one based on your preference. *

Eligible Resident's Address *

Please indicate what type of support you are looking for. *

Registering for a Vaccine

Determining if I am Eligible

Finding a Vaccine Clinic Near Me

Required

Submit

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