COVID-19 Vaccine Waitlist Form

Lets people join a waitlist to receive the COVID-19 vaccine, prioritized by risk factors and occupation.

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Name

Nombre

Apellido

Age

Gender

Female Male Prefer not to say

Date

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Are you a front liner or a first responder?

Yes No

What kind or type of first responder are you?

Police officer Firefighter Paramedic/EMS Healthcare worker Other

Are you over the age of 60?

Yes No

Are you a patient of a nursing home or long term care facility?

Yes No

Would you like to be on the waiting list?

Yes No

Do you need any assistance to get your vaccine?

Yes No

Comments, suggestions, or special instructions

Your Signature

Sign here

Date Signed

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