COVID-19 Vaccination Waiting List Home > COVID-19 Vaccination Waiting List COVID-19 Vaccination Waiting List 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Phone*Secondary PhonePhysical Address*NO P.O. Boxes Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence*AlbanyAlleganyBronxBroomeCattaraugusCayugaChautauquaChemungChenangoClintonColumbiaCortlandDelawareDutchessErieEssexFranklinFultonGeneseeGreeneHamiltonHerkimerJeffersonKingsLewisLivingstonMadisonMonroeMontgomeryNassauNew YorkNiagaraOneidaOnondagaOntarioOrangeOrleansOswegoOtsegoPutnamQueensRensselaerRichmondRocklandSaint LawrenceSaratogaSchenectadySchoharieSchuylerSenecaSteubenSuffolkSullivanTiogaTompkinsUlsterWarrenWashingtonWayneWestchesterWyomingYatesDo 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 InformationTerms*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* CAPTCHACommentsThis field is for validation purposes and should be left unchanged.