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Vaccination Waiting List Registration

If you are interested in receiving a Covid 19 vaccine and are a resident of Kentucky, please complete the registration form below. Due to limited supply of vaccine allocated from the state, it may take some time before you receive a call to schedule an appointment to receive the vaccine. We appreciate your patience as we work through this process.

To be eligible for vaccination, you must meet the age requirement of 18 or older.

First Name

Phone Number

Employer

Last Name

Birth Date

Clinic Location

Incase of cancellation, can you be at your selected clinic within 30 minutes to receive vaccine?

Yes

If you are under age 70, please mark any conditions if applicable

None

A Heart Condition

A Lung Condition

Immunocompromised Diagnosis

Cancer

Diabetes

Other

If you selected "other", please list below

I declare that the information I have provided is accurate & complete

“MCHC is a FTCA covered entity and its employees are covered individuals under 42 USC 233.”

MCHC receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

MCHC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

MCHC is dedicated to fulfilling all obligations as an Equal Opportunity Employer. MCHC insures that all applicants for employment and employees receive fair and equal treatment, regardless of race, color, religion, sex, sexual orientation, age, disability, national origin, or status as a veteran.

Please visit the contact us page to schedule an appointment or for general clinic information.

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