The City of Evanston is working to reach adults 65 years and older 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.)

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* 1. Are you interested in receiving a COVID-19 vaccine?

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* 2. Contact Information

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* 3. Age

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* 4. Special Accommodations Required

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* 5. If you are submitting this form on behalf of someone else, please provide your contact information.

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* 6. Other Comments

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