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COVID-19 Vaccine Interest - Contact Information

2. First Name*

3. Last Name*

5. Email Address

   Please provide at least one way to contact you; Email Address, Cell or Home phone number.

7. Cell Phone Number

   Cell phone that can receive text messages

8. Home Phone

   Phone Number for voice messages

9. Zip Code*

   Please Enter your Zip Code

11. Month of Birth*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

    Please select the month you were born.

12. Day of Birth*
    -- Select One --12345678910111213141516171819202122232425262728293031

    Please select the day you were born.

13. Year of Birth*

    Please enter the 4-digit year you were born

15. Occupation
    -- Select One --Construction, Landscaping, Other TradesCorrections OfficerEducation (teacher, support staff, daycare provider)FarmerFirst Responder EMTFirst Responder FirefighterFirst Responder PoliceFood Service - Restaurants, Catering, Etc.Healthcare - Direct Patient ContactHealthcare - No Patient ContactLong Term Care Facility ResidentManufacturerOffice Worker - Manager, Supervisor, Employee, ClericalOtherPlant WorkerPostal WorkerRetiredSchool Employee or ContractorService - Grocery Store EmployeeService - Public Transit WorkerService Transportation

    Please pick your occupation from the dropdown list.

16. Intellectual and / or Developmental Disabilities

    1. Yes
    2. Does not apply

    Persons with Intellectual and/ or Developmental Disabilities are included in Phase 1B

18. Do you have any underlying health conditions?

    1. Yes
    2. No
    3. Unsure

19. Health Condition
    -- Select One --CancerChronic Kidney DiseaseCOPD (Chronic Obstructive Pulmonary Disease)Heart Conditions (heart failure, coronary artery disease or cardiomyopathy)Immunocompromised (weakened immune system) from organ transplantObesity (BMI 30-40)Severe Obesity (BMI over 40)PregnancySickle Cell DiseaseSmokingType 2 Diabetes

    If you picked yes for an underlying health condition please select from the drop down

21. Do you need accommodations for a disability or language

    1. Yes
    2. No
    3. Unsure

23. Additional Comments

Leave This Blank:


24. Submit

* indicates a required field