temp2342134 – Department of Emergency Services

*** NOT A VACCINE SIGN-UP ***

COVID-19 VACCINE

PHASE 1A - NON-ESSENTIAL

*** INFORMATION SIGN-UP ***

This form IS NOT a registration to receive a vaccine. This form is to sign-up to receive regular updates about the COVID-19 vaccine.

FIRST NAME:

LAST NAME:

PHONE NUMBER

DATE OF BIRTH

dd-mm-yyyy

ARE YOU OVER 65+?

Yes

BARRIERS TO VACCINATION

COUNTY OF RESIDENCE

PREFERED LANGUAGE

I understand this form IS NOT a registration to receive a vaccine. I also understand this form is 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.

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1805 Cornwall Road, Lebanon, PA 17042

+1 717 272 7621

FAX: 717 274 1486

DEPARTMENTS

RESOURCES

+1-717-272-7621

Lebanon County Department of Emergency Services.