EmailMeForm
COVID-19 Vaccine Sign-up
Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
County
*
Phone
*
###
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*Please check the box below that best applies to you.
*
Childcare Worker
Healthcare Worker
First Responder
School Personnel
Essential Workers
Does not apply
* If Essential Worker please select an option below.
Corrections
Food & Agriculture
Manufacturing
U.S. Postal service workers
Public transit workers
Grocery store workers
Transportation and logistics
Food Service Shelter & Housing (Construction)
Finance
IT & Communication
Energy
Media
Legal
Public Safety (Engineers)
Water & Wastewater
Clergy
Have you been diagnosed by a doctor with any of the following health conditions? Check all that apply.
Cancer
Chronic kidney disease
COPD (chronic obstructive pulmonary disease)
Down Syndrome
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weakened immune system) from solid organ transplant
Obesity (body mass index [BMI] of 30 kg/m2 or higher but less than 40 kg/m2)
Severe Obesity (body mass index [BMI] equal to or greater than 40 kg/m2)
Pregnancy
Sickle cell disease
Type 2 diabetes mellitus