The purpose of this form is to identify individuals who are eligible for the COVID-19 Vaccine. As vaccines become available, Franklin County Public Health will contact these individuals for scheduling and distribution. The information entered into this form will be kept confidential and will be used soley for vaccine registration purposes.

This form wil ask for basic personal information, contact information, and vaccine eligiblity. You are required to attest that you are currently eligible or ineligible to receive the COVID-19 vaccine according to the requirements set forth by the New York State Department of Health. Current eligibility can we viewed on NYSDOH's website here.

DISCLAIMER: Filling out this form does not guarantee that the registrant will receive a COVID-19 vaccine. As vaccine distribution is managed by New York State, Franklin County Public Health cannot accurately predict when new doses will be available, or the number of doses we receive.

**If transportation is an issue, Franklin County will work with you to ensure you have a way of getting to your appointment.

By checking the box below, I affirm the following:

1. I acknowledge that the completion of this form does not guarantee if or when I receive a vaccine.

2. I agree that I will be contacted if or when the vaccines become available and it is my turn.

3. I have read the entire list of priority groups eligible for COVID-10 vaccination provided in the link above.

4. I hereby certify under penalty of law that I am eligible (or ineligible) for the COVID-19 vaccination, as selected above under "Eligibility".

5. I further agree that by checking this box and submitting this form that I am placing the legal equivalent of my handwritten signature as my attestation/certification.

If you experience any errors with the form, please contact us at Thank you.