This form will gather information about you, including your employment and health (allergies, medications, etc.) to determine your eligibility and properly schedule your vaccine appointment. At the end of this form, your determined eligibility will (1) enable you to schedule your vaccine appointment or (2) provide you with further instructions on how to schedule your vaccine appointment at a later date.

We ask that you answer truthfully in order for us to be able to distribute the vaccine as efficiently as possible.  All your information will be kept confidential to the extent of the law. If you have any questions or concerns about this form or the vaccine registration, you may contact (573) 757-8068 or (573) 757-8078.

In continuing on with this survey, you imply consent to participate in the vaccine registration.