Your Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Occupation*SelectRetiredEducationFood ServiceFood ProductionManufacturingPostal ServicesCorrectionsPublic TransitGroceryFirefighter/PoliceTransportationConstructionFinanceEnergyMediaLegalPublic SafetyWater and WastewaterOtherIf other, please specifyMedical Conditions Heart Disease Chronic Lung Disease Diabetes Cancer Smoking Solid Organ Transplant Sickle Cell Disease Daytime Phone NumberEmail Address Do you use MyChart*YesNoPrimary Care Provider*Matt SolversonMartin ClearyCheyanne KubatzkeNicolas CastilloLisa BourquinDonald HayLucas SuthersMelinda ThomasAmy TibbitsAny MHLC ProviderEducation*Do you understand that there will be education that you need to complete prior to receiving the vaccine? YesConsent*I am aware that my information may be shared with Lafayette County Public Health to facilitate vaccine coordination efforts. Vaccines may be administered through Public Health or MHLC. Yes