S7 COVID-19 Vaccine Registry Sign-up Form

The Southern Seven Health Department (S7HD) COVID-19 Vaccine Registry will be used to inform community partners and the general public of important updates related to the COVID-19 Vaccine availability in our Southern Seven counties. This includes the status of COVID-19 vaccination efforts, COVID-19 testing site information, and additional resources. Southern Seven may contact you by phone regarding COVID-19 vaccination opportunities based on your identified employment category (e.g., healthcare). Please note: completion of this form is not scheduling you an appointment for the COVID-19 vaccine.

S7HD is working to prioritize vaccinations in alignment with the recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP).
Vaccination is by appointment only and dependent on vaccine supply.
Vaccination prioritization will continue to change as COVID-19 vaccine supply increases in the coming weeks.

Name: *

First Name Last Name

IMPORTANT: Please do NOT register yourself more than once. We are receiving many duplicate submissions. If you have already submitted your information and think you may have made a mistake, please contact our Administrative Office at (618) 634-2297 and someone can assist you.

If you are a Healthcare Worker or First Responder, please call (618) 634-2297 to schedule an appointment.

If you are NOT a Healthcare Worker or First Responder, please fill in your information and wait for a member of our staff to contact you. Please DO NOT call our office to try to schedule an appointment. We are reaching out to individuals based upon what tier they fall into and the order that they have registered with us.

We appreciate your patience and understanding.

Birth Date *

Month Day Year

Email:

example@example.com

Phone Number *

Area Code Phone Number

County of Residence *

Please select which category best suits you or your organization/agency: *

Organization/Agency Name:

Title:

Other: