Green County COVID-19 Vaccine Interest Form for Eligible Groups
If you believe you are currently eligible to receive theCOVID-19 vaccine under the Wisconsin State Medical Advisory Committeeprioritization guidelines, please complete this from. Green County PublicHealth is currently working with other local vaccine providers to coordinatevaccination efforts, completing this form does not guarantee you will receivethe COVID-19 vaccine from Green County Public Health nor does this form reserveyou/your organization an appointment.
Are you completing this form for your organization or as an individual?
For my organiztion
As an individual
Name of organization's contact person
Street Address Line 2
State / Province
Postal / Zip Code
Number of people/employees/volunteers that qualify
Do you work or reside in Green County?
Please enter a valid phone number.
Please select that category that you/your organization are a part of
Frontline healthcare worker
Resident in skilled nursing/long term care facility
Child care provider
Enrolled in Medicaid long-term care program
Utility and communications infrastructure worker
Food supply chain
Staff of congregate living setting
Resident of congregate living setting
By checking "Yes", I attest the information listed above is accurate and that I/my organization is currently eligible to receive the COVID-19 vaccine.
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