COVID Registration Screening Form

Your Information

Full Name as it appears on license if applicable
Date of Birth*
Work email preferred
Text enabled if available

Eligibility Criteria

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

  • People age 18 years and older

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?*
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Confirm