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COVID-19 Vaccine Priority Groups Registration

2. 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.

   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.

4. First Name / Primer Nombre*

5. Last Name / Apellido Paterno*

7. Birth Date / Fecha de Nacimiento*
   Birth Date / Fecha de Nacimiento

8. Gender / Sexo*
   -- Select One --MaleFemale

10. Address / Direccion*

12. City / Ciudad*

13. State / Estado*

14. Zip Code / Codigo Postal*

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

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

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

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

20. Phone Number / Numero de Telefono*

21. Email Address / Correo Electronico

23. Confirm Phone Number/ Confirme Número de Teléfono*

27. Place of Employment / Lugar de Trabajo*

29. Position Title / Titulo*

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

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

    1. Yes
    2. No
33. Which statement best describes your daily work?*

    ¿Qué enunciado describe mejor su trabajo diario?

    1. Hospital staff working directly with patients who are positive or at high risk for COVID-19
    2. Long term care staff providing supporting laboratory, pharmacy, diagnostic and/or rehabilitation services
    3. EMS providers who engage in 911 emergency services (Pre-hospital care and transport)
    4. Home health care workers, including hospice care, who directly interface with vulnerable and high-risk patients
    5. Residents of long-term care facilities
    6. Staff in outpatients care offices who interact with symptomatic patients
    7. Direct care staff in freestanding emergency medical care facilities and urgent care clinics
    8. Community pharmacy staff who may provide direct services to clients, including vaccination or testing for individuals who may have COVID
    9. Public health and emergency response staff directly involved in administration of COVID testing and vaccinations
    10. Last responders who provide mortuary or death services to decendents with COVID-19
    11. School nurses who provide health care to students and teachers
    12. Individual over 65 years of age
    13. Individual over 16 years of age with a pre-existing medical condition(Must provide medical documentation)
35. 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?

    1. Yes
    2. No
37. IF YOUR INFORMATION IS NOT ACCURATE. YOU WILL NOT BE CONTACTED. PLEASE MAKE SURE TO PROVIDE CORRECT INFORMATION.

Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field