Coconino County Vaccine

COVID Registration Screening Form

Full Name*

Full Name as it appears on license if applicable

Date of Birth*

Email Address*

Work email preferred

Cell Phone Number*

Text enabled if available

Employer or Retired*

The following groups are currently eligible to register and receive COVID vaccination:

Healthcare workers
Adults with high risk medical conditions living in shelter or other congregate living settings
COVID response personnel
Childcare providers
Correctional facility workers
Emergency medical service personnel
Firefighters
Food and agriculture related occupations (packaging and distribution workers, grocery and restaurant workers)
Funeral services workers
Long term care facility staff
Long term care residents
Other essential workers (e.g., business and financial services, supply chain for critical goods, funeral services, critical trader, etc.)
People age 55 years and older
Police
Power and utility workers
State and local government workers that provide critical services for continuity of government
Teachers
Transportation and material moving occupations (public transportation providers, airlines, gas stations, auto shop workers, and other transportation network providers)

ID will be verified on site and you will be turned away if you do not meet the eligibility requirements.

Do you meet eligibility as defined above?*

Yes No

Which occupation or eligibility criteria most closely matches yours?*