If you think you are qualified to receive the COVID-19 vaccine under the current prioritization of eligibility as established by New York State (Phase 1a and Phase 1b- https://covid19vaccine.health.ny.gov/phased-distribution-vaccine#phase-1a), please provide your information below.  With this information the Westchester County Health Department will alert you when vaccine doses / appointments become available. You must understand that vaccine supply is currently limited and, therefore, subject to strict prioritization in accordance with Centers for Disease Control and New York State Department of Health directives. With that understanding, you will be required to certify under penalty of law that you are qualified under the current prioritization stated above. (Updated 1/12/2021)

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

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* 4. Email address

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* 5. Phone

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