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2. Please read and respond to each of the following. We will review your responses and add you to the standby list if you qualify.
4. I am currently eligible to receive the COVID-19 Vaccine based on the criteria set by NYS.*

   1. Yes
   2. No
6. I currently live or work in Schuyler County.*

   1. Yes
   2. No
8. I understand that this is not a wait list. By filling out this form, I am requesting to be added to the County's standby list. If someone is a no-show for their appointment - I may be called if I am the next person on the standby list.*

   1. Yes
   2. No
10. I understand that I will be expected to arrive in a timely manner if I am called and agree to fill in the spot for the person who did not show up for their appointment.*

    1. Yes
    2. No
12. I agree that I will still do my best to find an appointment elsewhere.*

    1. Yes
    2. No
14. If I am able to get my vaccine elsewhere, I will contact Schuyler County Public Health to remove my name from the standby list.*

    1. Yes
    2. No
16. Once you read and acknowledge the above, please enter your name, contact information, home address, and work address (if applicable) below.
18. First Name*
19. Last Name*
21. Email
22. Phone Number*
24. Home Address
26. Address1*
28. Address2
30. City*
31. State*
32. Zip*
34. Work Address
36. Address1
38. Address2
40. City
41. State
42. Zip
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field