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  1. This clinic is reserved for those aged 75 and over. If you do not meet this requirement, you are not eligible to receive your vaccination at this time. Please check back for additional clinics.
  2. I am the _________ of the individual named below.*
  3. I understand that my administration information and basic data may be sent to the state vaccine registry and CDC.
  4. The COVID-19 vaccine is voluntary. I am making a voluntary request for both doses of the COVID-19 vaccine and I agree to be vaccinated with both doses of the COVID-19 vaccine.
  5. By clicking "I have read and consent" below, I understand that this will be treated as an e-signature and will be treated as my consent and agreement to all of the above.
  6. Mark "N/A" if completing the form as an individual.
  7. Leave This Blank:

  8. This field is not part of the form submission.