Public Signup for Covid Contacting
Public Signup for Covid Contacting
Schoharie County is gathering contact information for those residents interested in receiving the COVID Vaccine
This information is to create a contact list for us to reach out when vaccine is available
This entry form is NOT for scheduling an appointment
Enter Information then scroll to bottom of page and click Save
First Name
.......
(mandatory)
Last Name:
.......
(mandatory)
Date of Birth:
Physical Street Address:
Village/Town:
Resident County:
State:
................
Zip Code:
One of the following three fields must be have information so we may contact you
Email Address:
Home Phone #:
.......
(enter as ###-###-####)
Mobile Phone #:
.......
(enter as ###-###-####)
Reason for wanting vaccine
Select from the following Primary Categories
Age 65 and Older
Chronic Illness
Essential Worker
Homeless Shelter
Employer:
Job Title:
................
