COVID-19 Vaccination

COVID-19 Vaccination for People 75 Years and Older

If you would like to join the waiting list for an appointment at our vaccination clinic, please complete the form below. We will contact you directly when we have an appointment available.

Completing this form is not a guarantee of an appointment. In Madison County alone, there are 24,000 people 75 years or older and we have a limited supply of vaccine. Information about additional vaccination locations is available on the ADPH website.

Request form to be put on the waiting list

We will contact you by phone when we have an appointment available. Completing this form is NOT a guarantee that you will receive an appointment as we have a limited supply of vaccine. If you are available on short notice to fill in gaps in our schedule, please indicate that below.

Fill out my online form.

You may also print the form by clicking here and email a scanned copy to This email address is being protected from spambots. You need JavaScript enabled to view it..