Homebound COVID-19 Vaccination Request Form

Homebound COVID-19 Vaccination Request Form
Franklin County Public Health (FCPH) is working hard to make sure that everyone who needs a COVID-19 vaccination has a way to get it. If you are a homebound individual or if you need vaccinations for a group of homebound individuals please complete the information below. Once your information is received, FCPH will reach out to discuss the details of the request.

NOTE: A minimum of 14 days of advance notice is required for all requests.
Select which option you would like to request: *
What are your barriers to getting vaccinated?
Name of organization (please enter N/A if you are an individual): *
Address: *

Street Address

Street Address Line 2

City

Postal / Zip Code
Primary Contact Name *

First Name Last Name
Primary Contact Phone Number *
Please enter a valid phone number.
Primary Contact Email *
example@example.com
Estimated number of people to be vaccinated: *
Please list up to 3 days that you would prefer. There is no guarantee that this date will be available. Reminder: A minimum of 14 days is required for all requests.

Month Day Year
Hour Minutes AM/PM Option
Please list up to 3 days that you would prefer. There is no guarantee that this date will be available. Reminder: A minimum of 14 days is required for all requests.

Month Day Year
Hour Minutes AM/PM Option
Please list up to 3 days that you would prefer. There is no guarantee that this date will be available. Reminder: A minimum of 14 days is required for all requests.

Month Day Year
Hour Minutes AM/PM Option
Should be Empty: