Use this form to submit your information to receive updates on the COVID-19 vaccine, including information on upcoming vaccine clinics. 

Note: Submitting information using this form DOES NOT place you on a "waitlist" or guarantee vaccination by the City of Racine Public Health Department. The Public Health Department will only use this information to provide you updates via email.

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Email Address

Question Title

* 4. Verify Email Address

Question Title

* 5. Phone Number

T