Four Corners Health Department LMTs

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Four Corners Health Department LMTs

(Polk, Bulter, York, Seward Counties)
Please let us know if you are interested in receiving the COVID-19 Vaccine. For those interested, we will share your info with FCHD so they can ensure they have the correct amount of vaccines available. They will contact you to coordinate with area partners for vaccination.

Sign in to Google to save your progress. Learn more

* Indicates required question

Name *

Your answer

Best email *

Your answer

Best Phone Number *

Your answer

Are you interested in getting the COVID-19 Vaccine *

Yes

No

Do you live in Four Corners Health Department District *

Yes

No

Do you work in Four Corners Health Department District? *

Yes

No

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy