2ND Dose Form to Test Covid 19 Vaccination Sign up second dose - AD IOS Step 1 of 2 50% Confirmation Number SAMPLE COVID-19 VACCINATION SIGN-UP YOU ARE REGISTERING FOR YOUR SECOND DOSE ***PLEASE READ AND DO THE FOLLOWING*** Photo ID required. ID or badge to show proof that you are first responder or healthcare is required. HiddenPhase1a1bHiddenCounty in which you reside or work*Nicholas CountyHiddenCounty in which you reside or work old* Please choose one of the followingYou will be turned away if you are not in this phase.70 and OverHealthcare WorkersFirst RespondersName* First Last Date of Birth* MM slash DD slash YYYY Date of Birth (For 70+)* MM slash DD slash YYYY HiddenAddress* Street Address City State / Province / Region ZIP / Postal Code Phone Number* Email HiddenFirst Dose* Yes No I had my first Covid vaccine 28 days ago. I understand that to receive my 2nd vaccine, I must present my vaccination card.* Yes HiddenConsent* Yes I have read this (HIPPA)HiddenConsent* Yes I have read this (EUA)*I understand that I am signing up for the SECOND DOSE of Covid vaccine.* YOU WILL BE TURNED AWAY IF YOU SIGN UP FOR THE WRONG DOSE.HiddenChoose a DayMarch 9March 12Schedule Date 1a*CAPTCHA