COVID-19 Vaccine Pre-Registration For Individuals 65 And Older

This is a pre-registration form for individuals who may qualify for a COVID-19 vaccine under this specific designation ONLY:

Pre-registration does not guarantee a vaccination appointment with Schenectady County Public Health Services.

First Name

Last Name

Phone Number

Zip Code

Date of BIrth

Attestation

Questions	I AGREE
I UNDERSTAND THAT THIS IS A PRE-REGISTRATION FORM, AND THE INDIVIDUAL WHOSE INFORMATION WAS SUBMITTED IN THIS FORM WILL NOT BE ABLE TO REQUEST A COVID-19 VACCINE UNTIL DEEMED ELIGIBLE UNDER NYS DOH AND CDC GUIDANCE.	I AGREE
I ATTEST THAT THE INDIVIDUAL WHOSE INFORMATION WAS SUBMITTED IN THIS FORM IS 65 YEARS OF AGE OR OLDER.	I AGREE