2. WASHINGTON COUNTY COVID-19 VACCINE INTEREST REGISTRY
4. Washington County is continuing to work to deliver vaccine to residents in a phased approach, in accordance with the New York State Phased Distribution Plan. The purpose of this form is to gather information from residents interested in receiving COVID-19 vaccination. Your answers to the questions will serve as an indication you are interested in receiving the COVID-19 vaccine from Washington County, if/when eligible and supply allows. While New York State requires Washington County Public Health Services to restrict administration of vaccine to certain groups, all eligible individuals can be vaccinated at New York State operated vaccination locations. Pharmacies, federally qualified health centers and ambulatory centers are also vaccinating specific groups, as directed / permitted by New York state.
5. 
7. Providing your information for this interest list DOES NOT RESERVE OR GUARANTEE a vaccination from Washington County Public Health. If/when vaccine is available based on your eligibility, you will receive additional information from Washington County. Proof of eligibility will be required at the time of vaccination. WE STRONGLY ENCOURAGE everyone to continue checking all available sources for vaccination as you await additional information.
9. FIRST NAME*
10. LAST NAME*
12. STREET ADDRESS*
14. TOWN / VILLAGE*
    -- Select One --ArgyleCambridgeDresdenEastonFort AnnFort EdwardGranvilleGreenwichHamptonHartfordHebronHudson FallsJacksonKingsburyPutnamSalemWhite CreekWhitehall
15. STATE*
16. ZIP CODE*
18. PHONE NUMBER (BEST CONTACT #)*
19. EMAIL ADDRESS (IF no email, enter [email protected])*
21. With the understanding that I will have to supply proof of my eligibility, I hereby certify under penalty of law that I am an adult, reside in New York State, and belong to one or more of the following groups eligible for vaccination. If my eligibility is based upon occupation, I further certify that I currently perform work in one of the below categories, either paid or unpaid, or I am a non-resident but perform such work in New York; and I am either required to have in-person contact with members of the public or with coworkers, or I am unable to work remotely. If my eligibility is based upon pre-existing medical condition(s), I further certify that, to the best of my knowledge and belief, I have one or more of these conditions.
23. VACCINE ELIGIBILITY CATEGORIES*

    1. 1A: Healthcare Worker
    2. 1B: Essential Personnel (as defined by NYS)
    3. Age Eligible (30+ on 3/30, 16+ on 4/06)
    4. Comorbidities / Eligible Medical Conditions (as defined by NYS)
    5. Homebound (unable to travel to a local POD site)
24. LIST ELIGIBILITY DETAILS (Employment Title, 65 & Over or Qualifying Reason(s)) **DO NOT LIST SPECIFIC MEDICAL CONDITIONS***
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

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