Please complete the information below if you are interested in taking the COVID-19 vaccine.

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* 1. What is your contact information so we can reach you to schedule an appointment when you qualify for the vaccine?

Name: Last, First, Middle Initial

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 2. What is your age?

18-24

25-34

35-44

45-54

55-64

65+

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* 3. Date of Birth?

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* 4. Have received any other vaccines in the last 14 days?

Yes

No

If yes, please specify what vaccination you received.

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* 5. Do you have any preexisting medical conditions, if so what are they?

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* 6. Are you an essential worker? if so, who is your employer?

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* 7. Sex:

Male

Female

Transgendered

Other

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* 8. Race:

White

Black

Asian

American Indian or Alaska Native

Pacific Islander

None Specified

Refused

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* 9. Hispanic Ethnicity?

Yes

No

Unknown

Refused