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COVID-19 Vaccine Priority Groups Registration

  1. If you meet the criteria as a priority group 1A or 1B, as defined by the Department of State Health Services, you may pre-register using the form below to receive the COVID-19 vaccine as available to the Department of Public Health. You will be placed on a waiting list and will be contacted (Phone, email, or text) when vaccines become available on a first come, first serve basis.

  2. WARNING

    PLEASE MAKE SURE YOUR PHONE NUMBER IS ACCURATE. YOU WILL NOT BE NOTIFIED IF WE DO NOT HAVE WHERE TO REACH YOU AT.

  3. ADVERTENCIA

    POR FAVOR, ASEGÚRESE DE QUE SU NÚMERO DE TELÉFONO ES EXACTO. USTED NO SERÁ NOTIFICADO SI NO TENEMOS A DÓNDE LOCALIZARLO.

  4. Is your employer enrolled as a COVID-19 vaccine provider?*

    ¿Está su empleador registrado como proveedor de la vacuna covid-19?

  5. Which statement best describes your daily work?*

    ¿Qué enunciado describe mejor su trabajo diario?

  6. Do you consent to sharing the information provided with COVID-19 vaccine providers to receive the vaccine?*

    ¿Acepta compartir la información proporcionada con los proveedores de la vacuna COVID-19 para recibir la vacuna?

  7. IF YOUR INFORMATION IS NOT ACCURATE. YOU WILL NOT BE CONTACTED. PLEASE MAKE SURE TO PROVIDE CORRECT INFORMATION.

  8. Leave This Blank:

  9. This field is not part of the form submission.