Central Oregon Public Health Departments

COVID-19 Vaccination Interest Form

Central Oregon Public Health Departments

COVID-19 Vaccination Interest Form


This form is for Central Oregon residents who are interested in receiving the COVID-19 vaccine. We will use the information you submit here to notify you when you are eligible to receive a COVID-19 vaccine and will also send vaccine updates as they are available.
Please enter a First Name.
Please enter a Last Name.
Please enter a valid Birth Date.
Please enter a valid Phone Number.
Please enter a valid Email Address.
Please enter a valid Zip Code.
Please select a Race.
Please select an Ethnicity.
Please select an answer.
Please select an Employment Category.

By checking this box, you attest that the information above is accurate to the best of your knowledge.
By checking this box, you agree to receive communication (email, text, phone) updates from Central Oregon Counties.
Please scroll up and fix the highlighted fields before submitting this form.