First Name *Middle Initial Last Name *Date of Birth *Click on "2021" in the datepicker to change the yearEmail *No Email I do not have an emailContact Phone Number *Address *Address 2 City *State *NYCTPANJMAZip *County *UlsterSullivanOrangeDutchessWestchesterUlsterPutnamGreeneDo you have a car, or suitable transportation to get to a Vaccination Site *YesNoDo you have a Healthcare Provider? *YesNoDo you have a health condition that puts you in a high risk category for complications with COVID-19? *YesNoConditions of Increased RiskDo you have the ability to provide documentation of this risk? *YesNoAre you an essential worker? *YesNoEssential Business ListOccupation *Food ServiceRetailGrocery DaycareHealthcarePublic SafetyPublic TransitLaw EnforcementGovernmentFirst RespondersTeachers /School StaffSkilled Nursing and Assisted Living Facility StaffOtherDescribe your Occupation *Do you regularly interact with the public? *YesNoAttestation *I affirm that the information provided is accurate to the best of my knowledge.CommentSubmit