COVID-19 Vaccine Registration Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### County of Residence Which dose are you registering for? * 1st Dose 2nd Dose Which phase best fits your situation? Phase 1: Health care workers with in-person patient contact Phase 1: Long-term care staff and residents—people in skilled nursing facilities, adult care homes and continuing care retirement communities Phase 2: Anyone 65 years or older, regardless of health status or living situation Phase 3: Frontline Essential Workers- The CDC defines frontline essential workers as workers who are in sectors essential to the functioning of society and who are at substantially higher risk for exposure to COVID-19. Phase 4: Anyone 16-64 years old with high-risk medical conditions that increase risk of severe disease from COVID-19 such as cancer, COPD, serious heart conditions, sickle cell disease, Type 2 diabetes, among others, regardless of living situation Phase 4: Anyone who is incarcerated or living in other close group living settings who is not already vaccinated due to age, medical condition or job function Phase 4: Essential workers not yet vaccinated. The CDC defines these as workers in transportation and logistics, water and wastewater, food service, shelter and housing (e.g., construction), finance (e.g., bank tellers), information technology and communications, energy, legal, media, public safety (e.g., engineers) and public health workers. Phase 5:Everyone who wants a safe and effective COVID-19 vaccination Unsure. Thank you!
