COVID-19 vaccine distribution

By completing the below form, you are attesting that you meet your state’s current vaccine eligibility criteria. See a full list of Kansas’ Phase 1 and 2 eligibility.

COVID-19 vaccine wait list sign-up

Required fields are marked with an asterisk *.

I have reviewed my state's eligibility criteria, and I attest that I am currently eligible to receive a COVID-19 vaccine *

Yes

First Name *

Last Name *

Phone Number *

Is this a mobile or landline number? *

Email Address *

If you do not have an email address, please write N/A

Preferred Location *

NOTE: Each person in a household must complete a separate form to request a vaccine. If you’d like to request an appointment time with another member of your household, please indicate it in the comment section below. We will make every effort to schedule appointments together.

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COVID-19 vaccine distribution

COVID-19 vaccine wait list sign-up