Covid-19 Vaccine Contact List

PURPOSE & PRIVACY

The purpose of this form is to identify St. Lawrence County residents who are eligible for the COVID-19 Vaccine so that as vaccines become available, St. Lawrence County Public Health can contact these residents for scheduling and distribution. The information entered on this form will be kept confidential and will be used solely for vaccine registration purposes.

ELIGIBILITY

You will be required to provide some personal information, contact information, and affirmatively attest that you are eligible for the vaccine according to the conditions specified on the New York State Department of Health's webpage here --> Phased Distribution of the Vaccine | COVID-19 Vaccine (ny.gov)

DISCLAIMER

Filling out this form does not guarantee that the registrant will receive a COVID-19 vaccine. St. Lawrence County Public Health cannot accurately predict when or how many doses will be provided to St. Lawrence County Public Health. Vaccine allocation, distribution, and priority groups are managed by New York State.

First Name

Last Name

Phone Number

Alternate Phone

E-mail

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Eligibility (choose all that apply)

Group 1A or 1B Essential Worker

Age 30+

Underlying Health Condition(s)

Not Yet Eligible, But Interested When Allowable

Transportation

What type of transportation will you use to arrive at the clinic? **If transportation is an issue, St. Lawrence County Public Health will work with you to ensure you have a way to get to your vaccine appointment.

Attestation / Certification

By checking this box, I affirm the following: .1. I acknowledge that the completion of this form does not guarantee if or when I receive a vaccine. .2. I agree that I will be contacted if or when the vaccines become available and it is my turn. .3. I have read the entire list of priority groups eligible for COVID-10 vaccination provided in the link above. .4. I hereby certify under penalty of law that I am eligible (or ineligible) for the COVID-19 vaccination, as selected above under "Eligibility". .5. I further agree that by checking this box and submitting this form that I am placing the legal equivalent of my handwritten signature as my attestation/certification.

CAPTCHA

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PURPOSE & PRIVACY

ELIGIBILITY

DISCLAIMER

Public Health

CONTACT INFORMATION