Vaccine Interest Form

If you are 65 years of age or older, you cannot make arrangements with your healthcare provider, and you are interested in receiving the COVID-19 vaccine, please fill out this form. Please continue to check our website and Facebook page for more information.

65 and older COVID-19 Vaccine Interest Form: https://form.jotform.com/210135164180140

If you are a phase 1A frontline healthcare worker including a caregiver for children in a special needs program such as Birth to 3 or Children's Long Term Support Waiver please fill out the form below:

Phase 1A COVID-19 Vaccine Interest Form: https://hipaa.jotform.com/210315036588049

The March 1st eligible groups for the COVID-19 vaccine include the following in priority order: 

  • Education and child care staff
  • Individuals enrolled in Medicaid long-term care programs
  • Some public-facing essential workers
  • Non-frontline essential health care personnel
  • Facility staff and residents in congregate living settings.

Please try to make an appointment with a healthcare provider, or pharmacy before filling out the COVID-19 Vaccine interest form.

March 1st Eligible COVID-19 Vaccine Interest Form: https://hipaa.jotform.com/210545112790145

If you have questions about eligibility for COVID-19 vaccine please visit: https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm