Vaccination Distribution Contact List
List to receive vaccine registration updates
Name
*
First Name
Last Name
Email
*
Confirmation Email
Email confirmation
Primary Phone Number
*
Format: (000) 000-0000.
Primary: Is this a cell phone?
*
Yes
No
City/Village of Residence
*
Which of the following applies to you:
*
Age 75 and older
Age 65-74
Non-health care frontline essential worker
Education/school staff or child care worker
Age 18-64 with high-risk medical condition(s)
Other
Other:
Employer Name
*
If not employed, put NA.
Your Title/Occupation
*
If not employed, put NA.
Submit
Should be Empty: