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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.

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First Name

Please enter a First Name.

Last Name

Please enter a Last Name.

Birth Date

Month January February March April May June July August September October November December

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910

Please enter a valid Birth Date.

Phone Number

Please enter a valid Phone Number.

Email Address

Please enter a valid Email Address.

Zip Code

Please enter a valid Zip Code.

Race Select a value... American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Decline to answer

Please select a Race.

Ethnicity Select a value... Hispanic or Latino Not Hispanic or Latino Decline to answer

Please select an Ethnicity.

Do you have one of the following medical conditions that may cause increased risk of severe illness from the virus that causes COVID-19? These include:

• Cancer
• Chronic Kidney Disease
• COPD (Chronic Obstructive Pulmonary disease)
• Down Syndrome
• Heart Conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
• Immunocompromised State (weakened immune system) from solid organ transplant
• Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
• Pregnancy
• Smoking
• Severe Obesity (BMI ≥ 40 kg/m2)
• Sickle Cell Disease
• Type 1 Diabetes Mellitus
• Type 2 Diabetes Mellitus

Select an answer... Yes No Decline

Please select an answer.

Your employment may impact your vaccine group, please select the employment category that you belong to: Select an Employment Category... Health care First responder K-12 educator or staff Post-secondary educator or staff Childcare staff Infrastructure (public works, utilities, water, public lands, first responder) Mass transit Supply chain Agriculture Food supply/grocery store Building support (plumbers, electricians, HVAC technician) Information Technology Gas station Transportation support (tire, tow, auto mechanic) College student Other

Please select an Employment Category.

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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.

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