Las Animas and Huerfano Counties COVID-19 Vaccination Registration Form

Las Animas and Huerfano Counties COVID-19 Vaccination Registration Form
Thank you for your interest in getting the COVID-19 vaccine when it is available! By getting the vaccine, you’re helping our healthcare workers get some respite, our businesses to re-open, our kids back in the classroom, and our public health epidemiologist’s the ability to do more effective contact tracing. Thank you!

Eventually, most residents will be able to receive the COVID-19 vaccine from their healthcare provider or a pharmacy. When the vaccine becomes available, we will notify the public on social media and via the local news.

If you would like to receive an notification when vaccine is available for your group within the state phased prioritization, please provide the information below.

Please note: vaccine may become available to you from healthcare providers without our knowledge.

HEALTHCARE WORKERS: Please check with your employer.

FIRST RESPONDERS (Firefighter, police, COVID-19 response personnel, correctional workers): please contact your employer.
Demographics entry form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select your vaccination group
If 'Other', please specify:
Please identify your employer if you are employed:
Is your employer located in the Las Animas or Huerfano Regions?

YesNo
If 'Other', please specify:
County of Residence
Should be Empty:

Las Animas and Huerfano Counties COVID-19 Vaccination Registration Form

Demographics entry form