Unvaccinated workers who are currently eligible for vaccination should use this form to submit your information to the Public Health Department. Your information will be used to connect you with local vaccinators who are able to accommodate you. 

Note: Submitting information using this form DOES NOT place you on a "waitlist" or guarantee vaccination. The Public Health Department will only use this information in an attempt to connect you with entities able to vaccinate you.

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

Question Title

* 6. Name of Employer

Question Title

* 7. Your Title/Role

Question Title

* 8. If registering for an employer, provide the number of eligible employees who are interested in receiving the vaccine.

T