Vaccination Information Request Form

The purpose of this form is to gather contact information for individuals wishing to receive the COVID-19 vaccine as it becomes available.  Currently, the COVID-19 vaccine is being rolled out to specific groups in phases defined by the New York State Department of Health [See if you are in a qualifying group].

This is not to pre-register for a COVID-19 vaccination appointment. After you fill out the Vaccine Notification Request form, your information will be added to a County mailing list, and you will receive email updates from the Ulster County Department of Health and Mental Health as to when you may be eligible to receive the vaccine. If all appointments for vaccine distribution at the County-led PODs (points of dispensing) are full, you will receive subsequent emails when additional appointments become available including on how to register for an appointment.

The two Points Of Distribution for Ulster County are: 

  • Kate Walton Field House at Kingston High School 
  • Ellenville High School 

Please note:  The information you submit is for the sole purpose of gathering contact information to provide public outreach for the COVID-19 vaccine.  The information submitted on this form will not be disseminated to any outside entity other than the Ulster County Department of Health. The information you submit will remain private.


Click on "2021" in the datepicker to change the year