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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 notification purposes)*

16. Email Address (for notification purposes)*

18. Email copy of vaccine waitlist submission by entering your email into the box below.

20. You will receive an emailed copy of this form. The copy of the form you receive via email is your confirmation that it was submitted and you are on the waitlist. You do not have to do another confirmation.

Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit Submit and Print

* indicates a required field