COVID Vaccination Registration Request Form

Please complete a survey for each individual in the household who are 16 years old or older.

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* 1. Name of person requesting vaccine

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* 2. What is the date of birth for the person to be immunized? (mm/dd/yyyy)

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* 3. If registering for a minor, please list the name of the guardian that will be bringing the child?

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* 4. Have you received a vaccine for the COVID-19 Virus?

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* 5. Are you willing to receive a Vaccine for the COVID-19 Virus?

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* 6. Do you have a preference of which vaccine you receive?

You have now completed Step 1 of the COVID-19 Vaccine Registration. Please be patient. We will contact you to complete the registration process as vaccines become available. Thank you.

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