Phase 1B – Department of Emergency Services

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COVID-19 VACCINE

PHASE 1B REGISTRATION

This form is a registration to receive a vaccine. This form is to sign-up to receive regular updates about the COVID-19 vaccine.

DISCLAIMER: AS OF 02/26/2021, THIS PHASE IS NOT CURRENTLY AUTHORIZED TO RECEIVE A VACCINATION BY PA DOH. THE TIMELINE FOR THIS PHASE IS UNKNOWN BUT REGULAR UPDATES WILL BE SENT.

FIRST NAME:

LAST NAME:

PHONE NUMBER

DATE OF BIRTH

dd-mm-yyyy

BARRIERS TO VACCINATION

COUNTY OF RESIDENCE

PREFERED LANGUAGE

EMPLOYER

EMPLOYER ADDRESS

EMPLOYER HUMAN RESOURCES PHONE #

OCCUPATION

WORK CATEGORY

I understand this form is a registration to receive a COVID-19 vaccine and to sign-up to receive regular updates about COVID-19. I declare that I have examined my responses on this form, and to the best of my knowledge and belief, they are true, correct, and complete.

I have read and agreed with the above statement.

You must agree in order to submit this form.