COVID-19 Vaccination Waiting List – Allegany County, New York

Do you currently fit into one of the Priority Phase Groups (Phase 1a or Phase 1b)?*

Check if you qualify here

Yes
No

Are you currently 60 years of age or older?*

Yes
No

Name*

First Last

Date of Birth*

Primary Phone*

Secondary Phone

Physical Address*

NO P.O. Boxes

Street Address Address Line 2 City State ZIP Code

County of Residence*

Do you currently have internet access?*

Yes
No

Do you have an e-mail address?*

Yes
No

Email Address*

Enter Email Confirm Email

Do you need assistance with registration?*

Yes
No

If you are entering information on behalf of an agency, please list your agency:

Additional Information

Terms*

By clicking 'I agree' below, I hereby agree and consent to your personal data being stored by Allegany County for the purposes of COVID-19 vaccination notification. This data may be shared with third party organizations for the sole purpose of COVID-19 vaccine registration. My consent and/or information may be removed at any point in time by submitting a request in writing to the Allegany County Department of Health. If you are calling in to the office, you are verbally consenting to your information being stored and shared based on the information above.

I agree*

Consent*

By clicking 'I agree' below, I attest, under penalty of law, that I am 18 years of age or older. When registered for the COVID-19 vaccine, I understand that I must provide proof of my age and I may be turned away if I do not have proof or if I am not 18 years of age or older. Please bring your insurance card as well as photo identification with you to the vaccination clinic. There is no implied or other guarantee that because your information is taken/entered that you are guaranteed a COVID-19 vaccine. The COVID-19 vaccine is currently based upon a prioritization of groups and individuals set forth by New York State.

I agree*

Initials of Person Entering Information*

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Phone

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