Van Buren/Cass District Health Department is administering COVID-19 vaccine based on priority groups determined by MDHHS and subject to vaccine availability.  This form determines phase and priority groups for individuals and workplaces and collects contact information.  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.  

Vaccination in one phase may not be complete before vaccination in another phase begins.  The timing of the start of vaccination in a phase is dependent upon the supply of vaccine from the manufacturer, how vaccine is allocated from the federal level to Michigan, and the capacity to administer vaccine to populations.  Further information can be found at www.vbcassdhd.org/covid-19-vaccine.

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* 1. Name

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* 2. County

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* 3. Age

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* 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)

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* 5. Email Address

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* 6. Phone Number

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* 7. Can this number accept text messages (Msg & data rates may apply)

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* 8. Address

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* 9. Are you currently employed?

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* 11. If employed, name of employer

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