Skip to content

UC Forms

Return to Ulster County's COVID Website

Vaccine Information Request

The purpose of this form is to gather contact information for individuals wishing to receive the COVID-19 vaccine as it becomes available. Filling out this form does not sign you up for a vaccine appointment. After you fill out this form, your information will be added to a County mailing list, and you will receive updates about vaccine availability, your eligibility, and how to schedule an appointment for vaccination.

Please note: This form can only accommodate one email address per person. If you are requesting information on behalf of someone else (particularly if they meet different eligibility criteria), please use a unique email address for each.

This is not a waiting list nor a lottery: people are not prioritized in order of when they signed up, nor removed from the list by the County for any reason. There is no need to fill out the form more than once.

Emails will come from webmailer@co.ulster.ny.us and may be signed by the Ulster County Department of Health and Mental Health, County Executive Pat Ryan, or other Ulster County government departments who have information to convey about the COVID-19 vaccine. Be sure to check your spam or ‘Promotions’ folder.

If you receive an email with a link to schedule an appointment at a County-led vaccination POD (point of dispensing) but all appointments are filled by the time you see the notification, please know that you will continue to receive subsequent emails as more appointments become available. There will be many opportunities to schedule a vaccination appointment, and you will remain on the email notification list indefinitely.

If you receive an email with a link to schedule an appointment after you have already scheduled one, this is not an indication that there is any problem with your appointment. You can use the unsubscribe link in any notification email to remove your email address from the notification list whenever you wish, or after you have been vaccinated. You will remain on the email notification list until you unsubscribe from it.

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.

First Name *

Middle Initial *

Last Name *

Date of Birth *

Phone *

Email *

No Email

I do not have an email

Address *

Address2

CIty *

State *

Zip *

County *

Do you have a car, or suitable transportation to get to a Vaccination Site *

Yes
No

Do you have a Healthcare Provider? *

Yes
No

Do you have a health condition that puts you in a high risk category for complications with COVID-19? *

Yes
No

Do you have the ability to provide documentation of this risk? *

Yes
No

Are you an essential worker?

Yes
No

Occupation

Describe your occupation

Do you regularly interact with the public? *

Yes
No

Language Preference *

Attestation *

I affirm that the information provided is accurate to the best of my knowledge.

Phone

(845) 340-3000 - 244 Fair Street, PO Box 1800, Kingston, NY 12402

© Ulster County Government - 2024