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COVID-19 Vaccine Eligibility Screening
Are you a resident of Kentucky?
*
-- Please Select --
Yes
No
Full Name
*
Address
*
City, State. Zip Code
*
Phone Number
*
Optional Secondary Phone Number
Email
Date of Birth
*
Frontline Essential Workers
Do any of the following categories apply to your employment?
*
Healthcare Worker
First Responder
Corrections
Education
Grocery Store
Food & Agriculture
Manufacturing
Public Transit
U.S. Postal Service
Other Essential Workers
Do any of the following categories apply to your employment
*
Energy
Finance
Construction
IT & Communication
Legal
Media
Public Saftey
Transportation
Water & Waste
Conditions
Do any of the following conditions apply to your health?
*
Diabetes
Heart Disease
Hypertension
Asthma
Chronic Respiratory Disease
Cancer
Stroke
Chronic Kidney Disease
Rheumatoid Arthritis
Lupus
Psoriasis
Down Syndrome
* Required field
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