- Home
- Government
- COVID-19
- Vaccine
- Vaccine Interest Form
Create an Account - Increase your productivity, customize your experience, and engage in information you care about.
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:
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