Sign up to be on a list to receive information on getting a COVID-19 vaccine. In anticipation of rolling out COVID-19 vaccination in our community, RCMS is putting together a list of people who are willing to get this vaccine. This list will be broken down by the priority tiers that State and County Public Health requires for vaccine distribution.

Availability of the vaccine, at this time, is totally controlled by the Public Health department. RCMS does not have the ability to directly obtain the vaccines – it must come through Public Health. When and how many vaccines will be provided to RCMS is decided by Public Health.

Having your name on this list helps distribution planning for the vaccine, but does not guarantee getting one. This is a voluntary list and the information is for RCMS's vaccine distribution plan only. When responding, please complete this survey for each individual separately.

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* 1. Contact Information

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* 2. Date of Birth

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* 3. Are you an established patient of RCMS?

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* 4. History of Anaphylaxis (a severe allergic reaction that requires to be treated right away)

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* 5. Profession/Volunteer

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* 6. Do you live in a nursing home?

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* 7. Are you experiencing homelessness?

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* 8. Do you live in a residential facility?

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* 9. Have you had COVID-19 diagnosed in the past?

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* 10. Do you have any pre-existing conditions?

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* 11. If yes, what is your pre-existing condition?

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