Language
  • English (US)
  • Spanish (Latin America)
  • Chinese
  • Chinese (Simplified Han)
  • Vietnamese
  • 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


  •    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
  • 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

  • Should be Empty: