COVID Vaccine Interest - Iowa City Senior Center
If you have not yet received your first dose of a COVID vaccine and would like the Senior Center to contact you regarding future opportunities to be vaccinated, please complete this form.

Completing this form does not mean you are signed up for a vaccine, but it will help us reach you more quickly with relevant information as it becomes available.
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Name (first and last) *
Phone number *
Email address *
City and county of residence *
Date of birth *
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For people age 64 and under: Do you have a medical condition that may increase your risk of severe illness from COVID-19?
(Conditions may include cancer, chronic kidney disease, COPD, diabetes, Down syndrome, heart condition, immunocompromised state, obesity, pregnancy, sickle cell disease, smoking, asthma, cerebrovascular disease, cystic fibrosis, hypertension or high blood pressure, neurologic conditions, liver disease, overweight, pulmonary fibrosis, thalassemia).
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Do you need help with transportation to a vaccine clinic (if help is available)? If so, please describe your needs.
Do you need help with language interpretation and/or translation? If yes, what language?
Is there anything else you would like us to know?
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