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COVID-19 Vaccine Pre-Registration

Date of Birth

First Name

Last Name

Phone

My phone can receive text messages

Email

Do you need translation or cultural supports at the site? *

No

Yes

Do you need a female vaccinator? *

No

Yes

Click here if you need Transportation assistance

Preferred appointment window?: * Required

9am

10am

11am

You will receive a confirmation message with your exact appointment time. Please arrive at your confirmed time.

There is no cost for the vaccine but please bring your insurance card, if you have one, or proof of identity if you do not have insurance.

Thanks for submitting!

© 2019 York County Community Action Corporation

207-324-5762
info@yccac.org

6 Spruce Street

Sanford, ME 04073

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