Vaccination Sign Up Form (Phase 1A)
This form is only for first responders and essential workers unable to get registered through other providers:

•Must be an active and licensed medical provider (provide medical license number)

• Must be currently employed or an active volunteer with an organization that provides licensed emergency medical service to Lebanon County (EMS and QRS).

• Must have run a call and had patient contact within the last 45 days (PCR validation may be required).

*If you you do not meet the requirements above consult the PA Department of Health’s website for guidance and availability here:
PA DOH COVID-19 WEBSITE: https://www.health.pa.gov/topics/disease/coronavirus/Vaccine/Pages/Vaccine.aspx or by Telephone at 1-877-724-3258

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Email *
This form is only for first responders and essential workers unable to get registered through other providers. If you are not one of those two groups your registration will be rejected
Agency / Organization affiliation *
Last Name *
First Name *
Birth Date *
MM
/
DD
/
YYYY
Cell Phone Number *
Email Address *
PA Medical License Number (EMT, EMR, PHRN, Etc.) - *Direct Support Personnel input "DSP" *
Have you tested positive for Covid-19 within the past 90 days? *
Scheduling and Appointments
Make sure that all your information is correct before submitting this form. After eligibility is validated we will be contacting you with specific scheduling availability and pertinent paperwork required in order to complete your vaccination.
A copy of your responses will be emailed to the address you provided.
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