COVID-19 Vaccine Interest Form for the General Population (not in priority groups 1A, 1B, 1C, or 2)

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This form is NOT registration for COVID-19 vaccination. It is a vaccine interest and contact information form. Please complete this form so the Health Department can contact you when we have more information about the vaccine registration process for your group. Please complete a separate form for each person who is interested in receiving the vaccine.

Name *

Street Address

City/Town *

Zip Code *

Phone Number

Email *

Do you drive or can someone else drive you to get a COVID-19 vaccination?

Yes

Other:

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Are you an adult age 16+ and not in priority groups 1A, 1B, 1C, or 2 (https://cchd.maryland.gov/covid-19-vaccination/)? *

Yes

Other:

Could you register for vaccination online or could someone else help you register for vaccination online?

Yes

Other:

Clear selection

Please add any additional information you feel we should know.

Submit

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