COVID-19 Vaccine Wait list

COVID-19 Vaccine Wait List
We will contact you via email once we have COVID-19 vaccine available for you. Please submit a form for each eligible person under current phase that needs to be vaccinated. While we are awaiting more allocation of the vaccine from DPH, you may want to check with the County Health Department to see if they can vaccinate you sooner.
Please complete all information below:
Name *

First Name Last Name
Date of Birth *

Month Day Year
Age *
E-mail *
Phone *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Do you have a preference on which Vaccine you receive.

Moderna (2 doses required) Pfizer (2 doses required) Janssen (Johnson & Johnson 1 dose vaccine) Any of the above listed (quickest option)
Should be Empty:

COVID-19 Vaccine Wait List