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COVID-19 VACCINE WAITING LIST
*THIS DOES NOT GUARANTEE YOU A VACCINE. YOU WILL BE PLACED ON A WAITING LIST. YOU WILL BE REMOVED AFTER TWO UNSUCESSFUL ATTEMPTS AT REACHING YOU.
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* Indicates required question
VACCINE RECIPIENT NAME:
*
Your answer
PARENT/GUARDIAN NAME IF VACCINE RECIPIENT IS A MINOR:
Your answer
IF I HAVE COMPLETED THE CONSENT FORM MY MINOR CHILD MAY RECIEVE HIS/HER COVID-19 VACCINE WITHOUT ME BEING PHYSICALLY PRESENT:
Yes
No
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TELEPHONE NUMBER:
*
Your answer
DATE OF BIRTH:
*
MM
/
DD
/
YYYY
ZIP CODE OF RESIDENCE:
*
Your answer
The following time works best for me:
*
8AM- 11AM
1PM-4PM
5PM-8PM
Is there anything additional you'd like Clarke County Public Health to know about you?
Your answer
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