COVID Vaccine Sign Up

Kingman County's COVID-19 Vaccine Sign Up

Please complete this form to let the Kingman Community Hospital know that you would like to receive the COVID-19 vaccine. We will use this information to place you on the list, so we contact you when vaccine is available. A survey needs to be completed for each individual.

Question Title

* 1. Do you belong to any of the following priority groups for vaccination? Please check all that apply.

Healthcare worker

Age 65 years or older

Person at high risk for severe illness from COVID-19 due to underlying medical conditions

Worker in essential and critical job

I do not belong to any of the above groups

Explain in further detail critical job and medical conditions

Question Title

* 2. Does anyone in your household belong to any of the following priority groups? Please check all that apply.

Healthcare worker

Age 65 years or older

Person at high risk for severe illness from COVID-19 due to underlying medical conditions

Worker in essential and critical job

No one in my household belongs to any of these groups (not including yourself)

Explain in further detail critical job or medical condition.

Question Title

* 3. Have you been laboratory confirmed to have COVID-19 within the last 90 days?

Yes

Unsure

Date of confirmation

Question Title

* 4. If you have children 18 years or younger, will you get a COVID-19 vaccine for your children as soon as it becomes available?

Yes

Unsure

I do not have children 18 years or younger

Question Title

* 5. What is your age group?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Question Title

* 6. Do you live in Kingman County, Kansas

Yes

No, but I work in Kingman County

No, but I see a doctor or access healthcare in Kingman County

Question Title

* 7. How do you receive information on the COVID-19 updates and vaccine availability?

Social Media

County Website

Newspaper

Radio/TV

Other (please specify)

Question Title

* 8. Contact information, so we can let you know when the vaccination is available for an appointment.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Primary Phone Number