Interested in Getting the COVID-19 Vaccine?

If you would like to receive the COVID-19 vaccine, please complete this interest form by providing basic information about yourself.
You can submit this form regardless of phase eligibility. This is only an interest form. If you are eligible for the vaccine in the current phase that is open, you will be directed to schedule an appointment as they become available. If you are eligible for the vaccine outside the current phase that is open, your information will be collected and you will receive notification from us when it is your turn to get the vaccine.  The information you provide will be kept private and secure. We will not ask for any personal information such as credit card numbers, passwords, or social security numbers.

Once you complete the form and hit submit, you will receive a confirmation email. This means we have your information and will reach out to you by email or phone to schedule your appointment when it is your turn. Each form submission is time stamped. We will contact interested community members in chronological order to schedule your appointment if you are eligible for vaccination.  Thank you for your interest in the COVID-19 Vaccine.
First Name *
Last Name *
Contact Number (numbers only) *
Email *
Age Range *
Please check all options that describe your work setting. *
* = required field