COVID Vaccine Pre-registration

Oneida County Government is working to deliver vaccine to our residents. The purpose of this form is to gather information from residents about their interest in receiving COVID-19 vaccination. We will ask some questions to determine when you are able to get the COVID-19 vaccine. The information entered on this form will be kept confidential and will only be used to connect you with where you can register to receive a COVID-19 vaccine in the future. We will communicate with you directly as appointments become available.

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Please enter the contact information for the registrant. (Required.)

First Name *

Last Name *

Address *

Address 2

City/Town/Village *

ZIP/Postal Code *

Email Address *

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Please enter your date of birth. (Required.)

Date

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Please enter your cell phone number (Required.)

Phone Number

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Please enter a landline phone number (optional)

Phone Number

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Are you the person being pre-registered? (Required.)

Yes

COVID Vaccine Pre-registration

Question Title

* Please enter the contact information for the registrant. (Required.)

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* Please enter your date of birth. (Required.)

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* Please enter your cell phone number (Required.)

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* Please enter a landline phone number (optional)

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* Are you the person being pre-registered? (Required.)

Please enter the contact information for the registrant. (Required.)

Please enter your date of birth. (Required.)

Please enter your cell phone number (Required.)

Please enter a landline phone number (optional)

Are you the person being pre-registered? (Required.)