COVID-19 INFORMATION ONLY SIGN-UP

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COVID-19

*** INFORMATION ONLY ***

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This form IS NOT a registration to receive a vaccine. This form is to sign-up to receive regular updates about COVID-19.

FIRST NAME:

LAST NAME:

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COUNTY OF RESIDENCE

I understand this form IS NOT a registration to receive a vaccine. I also understand this form is to sign-up to receive regular updates about COVID-19. I declare that I have examined my responses on this form, and to the best of my knowledge and belief, they are true, correct, and complete.

I have read and agreed with the above statement.

You must agree in order to submit this form.