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In-Home COVID-19 Vaccination Contact Form

The City of Evanston is working to reach all Evanston residents who are homebound due to medical conditions or are otherwise unable to attend the City’s COVID-19 vaccination events.

If you fit this criteria, please complete the form below so the City can coordinate in-home vaccination when the vaccine is available to you. (If you know someone who fits this criteria, please complete the form on their behalf.)
1.Are you interested in receiving a COVID-19 vaccine?
2.Contact Information(Required.)
3.Age(Required.)
4.Are you an Evanston resident with a disability?
5.If yes, do you identify with any of the following disabilities?
6.Special Accommodations Required
7.If you are submitting this form on behalf of someone else, please provide your contact information.
8.Other Comments