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.

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

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

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

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* 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?

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* 5. What is your age group?

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* 6. Do you live in Kingman County, Kansas

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

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

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