COVID-19 Vaccine Pre-Registration Waitlist For 65+ ONLY

BCHD is administering COVID-19 vaccines based on priority groups determined by MDHHS and subject to vaccine availability. This form will place you on a waitlist for the COVID-19 vaccine at BCHD and we we will notify you using the contact information provided when we are able to schedule you. If you are not 65+ please do not sign up for this waitlist. Please complete one (1) survey per person requesting vaccine.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Date of Birth - MUST BE 65 OR OLDER

Please Type or Choose Your Date of Birth

Date

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* 4. Email Address

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* 5. Phone Number

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* 6. Which contact method do you prefer? (e-mail will be the quickest way to receive information from BCHD)

Phone

COVID-19 Vaccine Pre-Registration Waitlist For 65+ ONLY

Question Title

* 1. What is your first name?

Question Title

* 2. What is your last name?

Question Title

* 3. Date of Birth - MUST BE 65 OR OLDER

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* 4. Email Address

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* 5. Phone Number

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* 6. Which contact method do you prefer? (e-mail will be the quickest way to receive information from BCHD)

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* 7. Zip Code of Residence