Contact Information

Please note: A separate form must be filled out for each person joining the waitlist even if the individuals signing up are at the same address.
*Information contained in this questionnaire is based on limited and preliminary guidance from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) and is subject to change as that guidance evolves.

Question Title

* 1. Do you live or work in the state of Illinois?

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