Form Instructions

Effective April 1, 2021: the Town of Stafford is partnering with local health districts and providers to offer free, in-town COVID-19 vaccination clinics for Stafford residents ages 18+. Please complete this form to get notified when vaccination appointments become available. 
  • Currently, only residents ages 18+ can receive their COVID-19 vaccination through the Town of Stafford municipal clinic.
  • Vaccination registration fields below reflect VAMS enrollment issued/required by the State.
  • CT Vaccine Portal: portal.ct.gov/Vaccine-Portal
  • The information you enter will only be used for purposes of scheduling your vaccination, and will be kept private.
Please note: 
Appointments are offered in the order in which they are received. Following submission of this form, you will be contacted when an appointment become available. 

The Town of Stafford utilizes trained volunteers, medical professionals, and emergency management personnel to safely operate local clinics. 

This is a town-hosted clinic for first vaccine doses.

Vaccination supply is limited and residents can and are encouraged to still register in VAMS portal to schedule their COVID-19 vaccine appointment or by contacting the Regional Call Center at  860-896-4568 (Mon-Wed 8:30 a.m.-4:30 p.m., Thurs 8:30 a.m.-7 p.m., Fri 8:30 a.m. - 1p.m.)

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* 1. First Name

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* 2. Last Name

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* 3. Gender

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* 4. Date of Birth

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* 5. Race

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* 6. Ethnicity

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* 7. Street Address

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* 8. City

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* 9. Cell Phone

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* 10. Alternative Phone

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* 11. Eligible Occupation or Age Eligibility Requirement

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