Rio Blanco County Public Health COVID-19 Vaccine Interest Form
This form is for individuals who would like to to express interest for the COVID-19 Vaccine clinics
Date of Birth
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
I would like to receive email updates for vaccination clinics.
County of Primary Residence
Which of the following describes you? (Select all that apply)
Adult with a high risk medical condition (obesity, diabetes, chronic lung disease, heart disease, chronic kidney disease, cancer or immunocompromised)
Interact directly with the public at work (such as grocery store workers, healthcare workers with direct patient care and school staff)
70 years of age or older
None of the above describe me
I affirm and certify that all of the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief?
Should be Empty: