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COVID-19 Vaccine Interest Form - Phase 1 ONLY

2. 

3. Park County Public Health
   Phase 1 Vaccine Sign-up for Notification Form

   Phase 1 Vaccine Sign-up for Notification Form

5. Please Do Not fill out this form if you do not qualify for this phase of the vaccine.
   There is no sign-up for Phase 2 and 3 at this time. Vaccine will likely be available to the general public in mid-2021. It will be provided through local health care provider offices and by 12 national pharmacy chains. The community will be notified via news and social media when it becomes available. If your primary residence, or place of employment is located in Park County and you qualify for Phase 1, please complete this form to indicate your interest in receiving vaccine as it is available. Answer all questions so we can determine your eligibility for phase placement. Identification is required. Completing this form does not guarantee you will receive a vaccine from Park County Public Health. We are doing our best given limited supply, capacity and guidance from the state. Once we are ready to vaccinate you we will contact you. This is a two-dose series, administered 28 days apart.

   There is no sign-up for Phase 2 and 3 at this time. Vaccine will likely be available to the general public in mid-2021. It will be provided through local health care provider offices and by 12 national pharmacy chains. The community will be notified via news and social media when it becomes available. If your primary residence, or place of employment is located in Park County and you qualify for Phase 1, please complete this form to indicate your interest in receiving vaccine as it is available. Answer all questions so we can determine your eligibility for phase placement. Identification is required. Completing this form does not guarantee you will receive a vaccine from Park County Public Health. We are doing our best given limited supply, capacity and guidance from the state. Once we are ready to vaccinate you we will contact you. This is a two-dose series, administered 28 days apart.

7. Who Should Not Get a Vaccine?
   The Moderna vaccine has received an Emergency Use Authorization (EUA) by the FDA and is considered to be highly safe and effective at preventing COVID-19 infections. This vaccine requires two doses to complete the series, spaced one month apart. Most people 18 years and older are able to safely receive the vaccine, except those who have: <ul><li>Tested positive for COVID-19 in the past 90 days;</li> <li>Had a severe allergic reaction after a previous dose of this vaccine; or</li> <li>Had a severe allergic reaction to any ingredient of this vaccine. </li></ul> If you do not currently qualify to receive a vaccine, please check back for updates and announcements.

   The Moderna vaccine has received an Emergency Use Authorization (EUA) by the FDA and is considered to be highly safe and effective at preventing COVID-19 infections. This vaccine requires two doses to complete the series, spaced one month apart. Most people 18 years and older are able to safely receive the vaccine, except those who have:

   • Tested positive for COVID-19 in the past 90 days;
   • Had a severe allergic reaction after a previous dose of this vaccine; or
   • Had a severe allergic reaction to any ingredient of this vaccine.

   If you do not currently qualify to receive a vaccine, please check back for updates and announcements.

9. First Name*

10. Last Name*

12. Phone Number*

13. Email Address*

15. Mailing Address*

17. City*

18. State*

19. Zip*

21. Date of Birth*
    Date of Birth

23. Please indicate how you qualify for Phase 1*
    -- Select One --I am 70 years or olderHealthcare personnel with direct contact with COVID-19 patientsHealthcare personnel with less direct contact with COVID-19 patients (e.g. home health, hospice, pharmacy, dental, etc.) and EMS. Emergency Services: Firefighters, law enforcement, correctional workers, and funeral servicesFrontline essential workers in educationFrontline essential workers in food and agriculture, and groceryFrontline essential workers in the U.S. postal service, public transit, specialized transportationFrontline essential workers in manufacturingFrontline essential workers in public health, human service workers, and direct care providers for individuals experiencing homelessnessContinuity of state workers: Essential officials from executive, legislative, and judicial branches of state governmentEssential frontline journalists

    We require identification and will verify your eligibility for the phase you are registering for.

24. Any known severe allergic reaction?*
    -- Select One --YesNo

    Please indicate if you have experienced a severe allergic reaction, such as anaphylaxis, generalized or systemic hives, or any respiratory compromise.

26. Please certify your registration*

    I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief.

    1. Yes
    2. No
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

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