COVID-19 Vaccine Interest Form for Essential Workers in critical utilities, transportation, food service, etc.
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 and is an essential worker in critical utilities, transportation, food service, etc.
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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?
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Are you an adult age 16+ and an essential worker? *
What essential job do you hold? *
Could you register for vaccination online or could someone else help you register for vaccination online?
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Please add any additional information you feel we should know.
Submit
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