COVID-19 Vaccine Interest Form

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Please complete this form if you are interested in receiving a COVID-19 vaccine. When we reach your priority group and vaccine is available, Allegany County Health Department or UPMC Western Maryland will contact you by email or phone to schedule a vaccination appointment.

Completing this form does NOT make you an appointment to be vaccinated. It may take several weeks, or longer, until you are contacted to schedule an appointment because of limited vaccine supply.

Name *

Age *

City or town *

Email address (enter "none" if you have no email) *

Phone number *

Do any of these apply? *

I live in a group home or congregate setting

I am certified as having a developmental disability

None of these apply

Do you have one or more of the following health conditions: cancer, cardiomyopathies, chronic kidney disease, COPD, coronary artery disease, Down syndrome, heart failure, obesity (body mass index over 30), organ transplant, pregnancy, sickle cell disease, smoking, Type 2 diabetes? *

Yes, I have one or more of these conditions.

No, I have none of these conditions.

I am employed in one of the following fields: *

Clergy

College or university

Corrections

Daycare or nursery school

Education PreK-12th grade

Food/agriculture production

Government

Grocery store

Healthcare provider (licensed, registered, or certified)

Lab services

Law enforcement, EMS, firefighter

Manufacturing

Public safety

Public transit

U.S. Postal Service

Utilities (water, power, gas)

Veterinarians and support staff

None of the above

Other:

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