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COVID - 19 Vaccination Registry

2. Provide your personal information for the Covid-19 Registry
4. This registry is for vaccine distribution for East Greenwich residents ONLY.
   Please use this form if you are over the age of 65 to provide your information now. This information will be used in future months to communicate directly with you when an opportunity becomes available to register you to receive the vaccine at a future clinic in accordance with the guidelines published by the State Department of Health. You will be required to present proof of identity and age at the time of vaccination.
6. Please Note
   The State of RI is currently supplying each City and Town with an extremely limited number of doses each week, and the Town of East Greenwich has no control over this process. It may be several weeks or more before you are contacted to schedule your vaccination. The State may also change this procedure in the future, and we will update our website accordingly.
8. Personal Information
10. First Name*
11. Last Name*
13. Date of Birth*
    Date of Birth
14. Age*
16. Address Information
18. Street Address*
20. City*
    -- Select One --East Greenwich
21. State*
    -- Select One --RI
22. Zip*
    -- Select One --02818
24. Do you have a home phone?*
    -- Select One --YesNo
26. Home Phone Number*
28. Do you have a mobile phone?*
    -- Select One --YesNo
30. Mobile Phone Number*
32. Do you want to provide an alternate contact?*
    -- Select One --YesNo
34. Alternate Contact Person (Optional)
36. First Name
37. Last Name
39. Alternate Contact's Relationship to You
40. Alternate Phone Number (Optional)
42. Email Address
43. Occupation
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 Submit and Print

* indicates a required field