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Protect Chicago Seniors Week Vaccine Sign-up
Use this form to sign-up Chicago seniors 65+ in your community who are interested in getting their vaccine shot at a local event in their community. Seniors who have signed up will either receive a registration link to complete or a phone call to help them register.
Appointments are limited to CHICAGO RESIDENTS ONLY. No one is confirmed until they are registered with and receive a time for their appointment. There will be no on-site registration and walk-ups will not be permitted.
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* Indicates required question
Select a community vaccination event.
*
(Select only one event only)
3/9/2021 West Pullman (must live in 60628, 60643 zipcodes)
3/10/2021 Burnside / Calumet Heights (must live in 60619 zipcode)
3/12/2021 Hermosa (must live in 60639, 60641, 60647 zipcodes)
3/13/2021 West Lawn (must live in 60629 zipcode)
3/14/2021 Auburn Gresham (must live in 60636, 60621, 60620 zipcodes)
3/14/2021 Lower W. Side / Pilsen (must live in 60608 zipcode)
3/14/2021 Brighton Park ( must live in 60623, 60608, 60609, 60632)
Name of person to be vaccinated (First and Last)
*
Your answer
Age (must be over 65)
*
Your answer
Zip code (will be asked for full home address during registration)
*
Your answer
Phone number
*
Your answer
Email address
Your answer
Will someone be assisting the registrant with completing registration?
*
No, only talk with registrant (skip the next question)
Yes, please speak with the designated contact person (please fill out the next question before submitting form)
Name, phone number, and email of the designated person who will complete the registration, if it is not the registrant,
Your answer
Preferred registration method
*
Email the registration link (will complete independently).
Receive a phone call to complete registration (only select if you don't have access to email; high call volumes may prevent timely callback)
Preferred language
*
English
Spanish
Other:
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