COVID-19 Vaccine Sign Up
THIS FORM IS FOR FAIRFIELD COUNTY, OHIO RESIDENTS ONLY.

Please sign up if you are interested in receiving the COVID vaccine once it becomes available locally. This form is being utilized to obtain the contact information of those interested, so you can be contacted with information on how to obtain the vaccine.

Please complete form - 1 per person

If you have trouble completing this form please call (740) 652-2802
  • Please place your first name in the first box and last name in the second box.
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  • Some employees may be offered the vaccine through their employment.