COVID-19 Vaccine Pre-Registration

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Please complete the form below to pre-register for COVID-19 vaccination in the Galion City Health Department (GCHD) jurisdiction. This is only pre-registration.

This information will be used to help the Galion City Health Department and its system partners plan for vaccine distribution as it becomes available in each phase.

Once we begin each vaccination phase, the GCHD will notify the individuals qualifying for that phase via the phone number and/or email address provided. Please double check your contact information as it is vitally important to ensure we can reach you when ready.

Each individual being vaccinated needs to complete a separate form, as some individuals within a family may be eligible for vaccination at different times.

Phase 1A: Healthcare Workers, People living or working in congregate settings (i.e. group homes), EMS Responders

Phase 1B: Persons aged 65 and older; People living with Severe congenital, developmental, or early-onset medical conditions; Employees in K-12 schools

Phase 1C: People living with Type 1 Diabetes, ALS, Bone Marrow Transplant recipients, and those who are Pregnant; Employees working in Child Care Services, Funeral Services, Law Enforcement and Corrections Officers

Phase 1D: Persons with Type 2 Diabetes or End-stage renal disease

Phase 1E: Person with Cancer, Person with Chronic Kidney Disease, Person with COPD, Person with Heart Disease, Person with Obesity

Phase 2A: Persons aged 60 and older
Phase 2B: Persons aged 50 and older
Phase 2C: Persons aged 40 and older
Phase 2D: Persons aged 16 and older

**Pre-registration does not guarantee your vaccination. Galion City Health Department employees will contact you to schedule an appointment based on vaccine availability and your designated phase.**

If you are completing this survey for someone else, please write your name and relationship to individual.

First Name of individual to be vaccinated *

Last Name of individual to be vaccinated *

Date of Birth *

(Please type in xx/xx/xxxx format or remember to select your birth year on mobile devices)

YYYY

Gender *

Female

Male

Other

Unknown

Current age as of form completion *

Race *

White

Black

Asian

American Indian/Alaska Native

Other

Native Hawaiian or Other Pacific Islander

Unknown

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Unknown

Street Address (including apartment number if relevant) *

City of residence *

State of residence *

Postal/Zip Code of residence *

Phone Number *

Please DOUBLE-CHECK your phone number for accuracy. Phone numbers should include 10 digits and must be entered without dashes (e.g. XXXXXXXXXX)

Select your employment sector *

Retired

Unemployed

Agriculture and food manufacturing

Child care or Child Care Services

Dental care

Elder care/adult day care (daytime only)

Fire/EMS

Food service (restaurants/caterers, etc)

Funeral home or other mortuary services

Government agencies

Grocery store/convenience store

Law Enforcement & Corrections Officers

Long term care/skilled nursing facility

Manufacturing

Outpatient services (speech/occupational/physical/behavioral therapy, mental health services, etc.)

Personal care services (barbers, hair/nail salons, spas, etc.)

Pharmacy

Primary care providers

Postal mail and package services

Religious organizations

Retail

Service-based business

Shelters (homeless, domestic violence, etc)

Urgent Care

Utility (including internet, telecommunications, and waste management)

Transportation (trucking, mass transit operations, taxi operations)

What is your position/title at your primary place of employment? *

If you are retired or currently not working, please enter either RETIRED or UNEMPLOYED.

Which of the following describes you? (Select the choice that best fits you) *

Age 80 and older

Age 75-79

Age 70-74

Age 65-69

Age 60-64

Age 55-59

Age 50-54

Age 45-49

Age 40-44

Age 18-39

Age 16-17

Person with Cerebral Palsy

Person with Spina Bifida

Person with Severe Congenital Heart Disease (Requiring Hospitalization in the last year)

Person with Type 1 Diabetes

Person with Type 2 Diabetes

Person with an Inherited Metabolic Disorder (i.e. Phenylketonuria)

Person with a Severe Neurological Disorder (i.e. Epilepsy, Hydrocephaly, Microcephaly, MS, Parkinson’s)

Person with Severe Genetic Disorders (i.e. Down Syndrome, Fragile X, Prader Will Syndrome, Turner Syndrome, Muscular Dystrophy)

Person with Severe Lung Disease (i.e. Cystic Fibrosis, COPD, Emphysema, Severe Asthma (Requiring Hospitalization in the last year))

Person with Sickle Cell Anemia

Person with Alpha and Beta Thalassemia

Person that is Pregnant

Person that is a Bone Marrow Transplant Recipient

Person that is a Solid Organ Transplant Patient

Person living with ALS

Person with End Stage Renal Disease

Person with Cancer

Person with Chronic Kidney Disease

Person with COPD

Person with Heart Disease

Person with Obesity

None of the above but interested in receiving the COVID-19 vaccine

I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. *

Yes

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