Marin County COVID Vaccination Interest Form

Marin County COVID Vaccination Interest Form
Para español, haga clic en las opciones de idioma en la parte superior derecha del formulario
If you live in Marin County and are interested in receiving the COVID-19 vaccine, you can sign-up to be notified when you’re eligible, based on the State vaccine priority list. You can receive the communication by email, text message and/or pre-recorded voice message, and thru California Relay Service/711.

We’re asking you about your work, your age, and if you have certain health conditions, because that will determine your eligibility based on the State vaccine priority list. You will not be asked about immigration status and we won’t share your information with anyone.

For eligible residents, completing this form will also add you to an outreach list for available vaccine appointments at County-sponsored vaccination sites. This form, however, does not replace any signup or appointment opportunities offered by other providers in Marin. We encourage all residents to inquire with their primary medical providers or other vaccine providers about vaccine availability.

Filling out this form does not mean you will automatically receive a vaccine appointment. Vaccine supply is still limited. Even though you may be eligible, it may be several weeks until you are able to schedule an appointment.

You can sign up to get notifications for other people, or you can sign-up on someone’s behalf (for example, friends/family who do not have access to internet). People without internet access can receive assistance with filling out the vaccine interest form by calling 415-473-7191 (vaccine appointments cannot be scheduled by calling this number).

For more information, please see our website: https://coronavirus.marinhhs.org/vaccine

Have a question? You can email us online: https://coronavirus.marinhhs.org/contact
First Name *
Last Name *
How do we notify you? (Select all that apply) *

Email Text Phone (Pre-recorded message) California Relay Service / 711
How do we notify you? *

Email Text Pre-Recorded Message by phone Email and Text Email and Pre-Recorded Message by phone Email text and Pre-Recorded Message by phone
Email (if you provide an email address you will receive an email confirmation) *

Confirmation Email Please enter your email twice and make sure they match
Phone Number for Text Messages *
We will not call the number. Text message only.
Phone Number for Pre-Recorded Messages *
Robocall Notification
California Relay Service/ 711 *
Enter Phone Number
Are you currently experiencing homelessness? *

Yes No
Zip Code *
Age Range *

75+ 65-74 50-64 18-49 under 18
Are you Hispanic or Latinx? *

Yes No
What is your race? *
What is your race? *

American Indian or Alaska Native Asian Black or African American Hispanic / Latino / Latina Native Hawaiian or Pacific Islander White Multiracial Other
Language Preferences *
Language Preferences *

English Spanish Chinese Vietnamese Other
Which best describes you? *

Kaiser Permanente member Sutter Health member MarinHealth Medical Network Marin Community Clinic Patient MediCal (including Partnership Health) None of the above, but have health insurance None of the above, and am uninsured
Do you work from home? *

Yes No
Health Conditions
- Cancer, current with debilitated or immunocompromised state
- Chronic kidney disease, stage 4 or above
- Chronic pulmonary disease, oxygen-dependent
- Down syndrome
- Immunocompromised state (weakened immune system) from solid organ transplant
- Pregnancy
- Sickle cell disease
- Severe obesity (Body Mass Index ≥ 40 kg/m2)
- Type 2 diabetes mellitus with hemoglobin A1c level greater than 7.5%
Additional Factors

If as a result of a developmental or other severe high-risk disability one or more of the following applies:
- The individual is likely to develop severe life-threatening illness or death from COVID-19 infection
- Acquiring COVID-19 will limit the individual's ability to receive ongoing care or services vital to their well-being and survival
- Living in a home, apartment, or abode of their choosing (not including a hospital, nursing home, assisted living, or licensed care facility).
- Providing adequate and timely COVID care will be particularly challenging as a result of the individual's disability
Do you have one or more of the health conditions described above? *

Yes No
Do you require assistance with online registration or accommodations at the vaccine site? *

Yes No
Are you able to walk for more than 50 yards, unassisted? *

Yes No
Do you have a ride or transportation to a vaccine distribution location? *

Yes No
Please select business/industry you work in *

Chemical and Hazardous Materials Communications and IT Critical Manufacturing Defense Education and Childcare Emergency Services Energy Financial Services Food and Agriculture Government operations/community based essential functions Healthcare worker Industrial, Commercial, Residential and Sheltering facilities and services Transportation and logistics Water and Wastewater Other
If you have a disability and need assistance with filling out this form, accommodations may be made by phoning 415-473-4381 (Voice), CA Relay 711 or by e-mail at DisabilityAccess@MarinCounty.org

Please check Health Information Privacy Resources for HIPAA information
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