Please fill out this form if you are interested in receiving the COVID-19 Vaccine.
Reminder: By filling this out, you are NOT signing-up or confirmed for an appointment. We will contact you by phone or email if or when you are eligible to sign-up for a vaccination appointment.

If you have previously had a severe allergic reaction to food, medicine, or another vaccine, you are not eligible to receive the vaccine at our site, however we encourage you to check with other providers listed here

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* Personal Information 

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* How old are you? 

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* Do you have any of the following medical conditions? 
- Cancer 
- Chronic Kidney Disease 
- Diabetes 
- Down Syndrome 
- Heart Failure, cardiomyopathies, coronary heart disease
- Obesity (> 30 BMI)
- Sickle Cell Disease
- Solid Organ Transplant

By filling out this form, you are not signing up for a confirmed appointment. When we have vaccines available, we will contact you to schedule your appointment.