COVID-19 Individual Vaccination Registry

Van Buren/Cass District Health Department is administering COVID-19 vaccine to anyone 18 years and older. We will notify you using the contact information provided when we are able to schedule you for COVID-19 vaccination, please ensure the information is accurate before submitting.

We encourage you to also check our website at www.vbcassdhd.org/covid-19-vaccine/ for current vaccine appointment offerings. Vaccine clinics are added frequently.

*1.Name(Required.)

*2.County(Required.)

Cass

Van Buren

Other (please specify)

*3.Age(Required.)

65 years of age or older

18-64 years old

Under 18 years old

*4.Do you have an underlying health condition that would put you at risk of severe illness due to COVID-19 infection? (COPD, hypertension, chronic kidney disease, heart disease, diabetes, obesity or other conditions that put you at high risk of negative COVID-19 outcome)(Required.)

Yes

5.Email Address

6.Phone Number

7.Address

Address

City/Town

ZIP/Postal Code

*8.Are you currently employed?(Required.)

Yes

9.If yes, what type of setting are you employed in?

Please note: If your field is not listed below, unless you meet other priority criteria such as age or underlying health conditions, you will be included in Phase 2

If you believe your employment setting is included in a priority group but is not listed as an option in the dropdown, please provide that here.

10.If employed, name of employer

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