Covid 19 Vaccination Sign up – Powell County

Your booster shot will be at the Powell County Health Department

376 North Main St, Stanton

Step 1 of 2

Confirmation Number
COVID-19 VACCINATION SIGN-UP (POWELL COUNTY)

YOU ARE REGISTERING FOR YOUR BOOSTER DOSE

***PLEASE READ AND DO THE FOLLOWING***
- Bring ID
- CDC vaccine card
- Please Wear a Mask
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County in which you reside or work
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County in which you reside or work (old)*
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Which of the following categories best describes you? Please be truthful, this information will be verified.*
Note: If you meet multiple criteria, you should select the category that puts you eligible for an earlier Phase. *
List of Essential Workers
(food & agriculture - veterinarians, manufacturing, U.S. Postal service workers, public transit workers, grocery store workers, food service, shelter and housing, construction, finance, IT and communication, energy, media, legal, public safety - engineers, water and wastewater)
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
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Date of Birth ( 40+)*
MM slash DD slash YYYY
Phone Number*
Email
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Second Dose*
You certify that you understand that in order to receive the 2nd dose Covid Vaccine the card from your 1st dose must be presented.

Yes

I attest that I am eligible for a booster based on the above guidelines*

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I CERTIFY this is my FIRST dose.*

Yes I Understand
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Consent*
Yes I have read this (HIPPA)
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Consent*
Yes I have read this (EUA)*
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You certify that you understand that in order to receive the Booster shot, you must present your Covid Vaccine card showing your first two shots*
Yes
Type of Vaccine*
Schedule Date*
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Schedule Date (Thursday)*
CAPTCHA

Your booster shot will be at the Powell County Health Department

376 North Main St, Stanton

Step 1 of 2

COVID-19 VACCINATION SIGN-UP (POWELL COUNTY)

YOU ARE REGISTERING FOR YOUR BOOSTER DOSE

***PLEASE READ AND DO THE FOLLOWING***

Bring ID

CDC vaccine card

Please Wear a Mask

PLEASE READ AND DO THE FOLLOWING