NORTHEAST HEALTH DISTRICT - Private Educational Organization COVID Vaccine Registration
THIS FORM IS FOR EDUCATIONAL ORGANIZATIONS ONLY! If you are an individual wishing to pre-register, please visit: https://bit.ly/NEHDCOVIDVaxRegistration
Organization Name
*
Organization Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
COUNTY (Where Organization is Located)
*
Please Select
Barrow
Clarke
Elbert
Greene
Jackson
Madison
Morgan
Oconee
Oglethorpe
Walton
IF your organization is NOT located in one of our 10 counties, please reach out to your county or district public health office.
Point of Contact Name
*
First Name
Last Name
Point of Contact EMAIL (work)
*
example@example.com
Point of Contact PHONE (work)
*
Please enter a valid phone number.
Estimated Number of Staff to be Vaccinated
*
Enter just a NUMBER (MUST be greater than 1)
COMMENTS or NOTES
Submit
Should be Empty: