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Vaccine Wait List

2. DISCLAIMER: Santa Rosa County is collecting names and contact information for county residents 65 and older who would like to be vaccinated. We will use this list to schedule vaccination appointments when vaccines are available in Santa Rosa County. Appointment dates and times will be emailed or texted.

4. This form is to allow citizens to request an appointment for a COVID-19 vaccination as soon as supplies are available.

6. Note: If you are entering this information for a friend or a relative, you will need to enter their contact information. If they do not have a cell phone number or email, please list your own so that you can pass the information along to them.

8. First and Last Name*

9. Date of Birth*

11. Address*

12. City*

13. Zip Code*

15. Cell Phone Number (for appointment notification)*

16. Email Address (for appointment notification)*

18. One you submit this form, you do not have to submit any other confirmation. Submitting this form adds you to our waitlist.

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19. Submit Submit and Print

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