COVID-19 Vaccination Interest Form
Please complete if you are interested in receiving a COVID-19 vaccine from Stickney Public Health District. This is for those individuals who live or work within our jurisdiction. Please complete and submit the form only once.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Age
*
Do you have one or more of the following underlying conditions:
Cancer
Chronic kidney disease
Chronic obstructive pulmonary disease
Diabetes
Heart disease
Sickle cell disease
Pulmonary disease
Obesity
Occupation
*
Submit
Should be Empty: