Community Covid-19 Vaccination Demographics

Fill out this form to let us know that you want the COVID-19 vaccine as soon as it is available to you. Filling out this form does not guarantee that you will receive the vaccine in our first allotment. The COVID-19 Vaccine Task Force is working hard to equitably distribute the vaccine. The amount of vaccine we receive is determined by the state and federal governments, the allotment per location is unknown at this time.

What is today's date?*

First Name*

Middle Initial

Last Name*

Are you a SEARHC Beneficiary?*

You are eligible to be a SEARHC Beneficiary by being part of a recognized tribe or are of Alaska Native/Native American descent.

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What town do you live in?*

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What is your birthdate?*

Are you male or female?*

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age group

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Parent/Guardian

What is your Occupation?

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Are you a SEARHC Patient?*

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Are you signed up for the Patient Portal?*

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What is your email?*

If you don't have one, enter 'None'. Please enter the email address you would like to receive communication about the COVID-19 vaccine. You may enter multiple email addresses, separated by a comma. They do not have to be your work email. Be sure to double check for typos.

What is your phone number?*

If you don't have one, enter 'None'.

Mailing address: What is your street address?*

Mailing address: What is your town?

Mailing address: What is your state and zip code?

What type of vaccine are you willing to receive? Check all that apply.*

Not all vaccines are available in every community. You will be notified when vaccine clinics in your area have your preferences available.

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