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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Select a community vaccination event. *
(Select only one event only)
Name of person to be vaccinated (First and Last) *
Age (must be over 65) *
Zip code (will be asked for full home address during registration) *
Phone number *
Email address
Will someone be assisting the registrant with completing registration? *
Name, phone number, and email of the designated person who will complete the registration, if it is not the registrant,
Preferred registration method *
Preferred language *
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