COVID-19 Vaccination Registration Form

Para completar este formulario en español, haga clic aquí.

By completing this registration form you are agreeing to receive COVID-19 vaccine appointment notifications from DuPage County Health Department or our local healthcare partners.

Registering here allows us to contact you with specific information when appointments are available. Please note: you will not be able to schedule an appointment until the time is right!
- Vaccination is by appointment only and dependent on vaccine supply.
- Eligible individuals will be asked to provide verification of their eligibility through either photo ID to confirm age-based eligibility or employment verification (Employee ID Badge, check stub, state licensure or certificate) to identify occupational eligibility.
- Based on limited supply of COVID-19 vaccine across the country and in DuPage County we anticipate it may take approximately 12 weeks to vaccinate the nearly 270,000 individuals in DuPage County who meet Phase 1b criteria.
- As the vaccine supply provided by the State of Illinois/IDPH is allocated based on county jurisdiction, DCHD is further prioritizing its administration of vaccine for individuals who reside, work, or attend college/university in DuPage County.
- Individuals presenting for vaccination at a DCHD location may be asked to provide verification of residence, employment, or school attendance within DuPage County.
- Vaccination prioritization will continue to change as COVID-19 vaccine supply increases in the coming weeks.
  
  For more information please visit: www.dupagehealth.org/covid19vaccine
Name: *

First Name Last Name
Email: *
example@example.com
Phone Number *

Area Code Phone Number
Organization/Agency Name:
Title:
Please select which catgory best suits your role in Phase 1a:

Healthcare (including EMS and Dental) Long-term Care Funeral Home
Please select which category best suits your role in Phase 1b:

65 and Older First Responders - Firefighters (including volunteers), Law Enforcement Officers (LEOs), 911 Dispatch (Public Safety Answering Point PSAP), Security Personnel, School Officers. Corrections Officers/Inmates (Jail Officers, Juvenile Facility Staff,Workers Providing In-Person Support, Inmates) Education Workers (Congregate Child Care, Pre-K through 12th grade): Teachers, Principals, Student Support, Student Aids, Day Care Workers. Food and Agriculture Workers (Processing, Plants, Veterinary Health, Livestock Services, Animal Care) Grocery Store Workers (Baggers, Cashiers, Stockers, Pick-Up,Customer Service) Manufacturing Workers (Industrial production of goods for distribution to retail, wholesale or other manufacturers) Postal Service Workers Public Transit Workers (Flight Crew, Bus Drivers, Train Conductors, Taxi Drivers, Para-Transit Drivers, In-Person Support, Ride Sharing Services) Shelters/Adult Day Care (Homeless Shelter, Women's Shelter, Adult Day/Drop-In Program, Sheltered Workshop, Psycho-Social Rehab) Snow Removal Workers
Please select which category best suits your role in Phase 1c:

Persons aged 16 to 64 years old with medical conditions that increase the risk for severe COVID-19. Conditions include obesity, diabetes, pulmonary disease, heart condition including hypertension, kidney disease, cancer, immunocompromised, sickle cell and pregnancy. Transportation and Logistics Food Service Housing (e.g., Construction) Finance (e.g., Bank Tellers) Information Technology and Communication Energy Media Legal Public Safety (e.g., Safety Engineers) Water and Wastewater Public Health Workers
Should be Empty: