COVID-19 Vaccination Registration Form

Please answer the following question to complete the registration process.
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Do you qualify for the COVID-19 vaccine per link: these guidelines|https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html|?

Please provide the following information to complete the registration process.
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Required Fields
Please answer the following questions to complete the registration process.
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This question helps us better understand who we are reaching. Your answer does not affect your eligibility to receive the vaccine in any way.

Select an ethnicity

This question helps us better understand who we are reaching. Your answer does not affect your eligibility to receive the vaccine in any way.

Select a race

Select all that apply. link:Visit the CDC's website to learn more.|https://www.cdc.gov|

Select all that apply. link:Visit the CDC's website to learn more.|https://www.cdc.gov|

link:Visit the CDC's website to learn more.|https://www.cdc.gov|

You're almost done! Please verify your contact information.
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We will use the email address or phone number you provide to contact you when it's time to schedule your vaccine appointment.

Warning: You won't be able to change your contact info after the form is submitted.
First name
Last name
Date of birth
Email address
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Cell phone
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Address
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Do you have a medical condition that **puts you at increased risk** of severe illness from the virus that causes COVID-19? Not Entered
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Note that submitting this pre-registration form does not schedule a vaccination appointment. This submission adds you to a COVID-19 vaccine waitlist that will alert you when you can begin the scheduling process.

You are not currently eligible to register for the COVID-19 vaccine.

Read guidance from the link:Centers for Disease Control and Prevention (CDC)|https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html| to learn more.

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