Village of Skokie COVID-19 Vaccine Opt-Out

If you have already received the COVID-19 vaccine and/or would like to be removed from the Skokie COVID-19 Vaccine Pre-Registration list, please enter your contact information below. Submission of this survey will remove your place in line for the vaccine.

*1.CONTACT INFORMATION:(Required.)

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Primary Phone Number:

E-mail Address:

Current Progress,

0 of 1 answered

Powered by

See how easy it is to create surveys and forms.

Privacy & Cookie Notice