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Please complete this form to sign up for COVID-19 vaccination at our clinic.
We will add your name to our list and will contact you to schedule an appointment when you are eligible to receive the vaccine.
Please review our
COVID-19 Vaccine Information
page to learn more about the Randolph Community Clinic vaccination program.
*
Indicates required field
Name (First, MI, Last):
*
Date of Birth:
*
Please use format mm/dd/yyyy when entering date of birth.
Phone Number:
*
Please use format xxx-xxx-xxxx when entering phone number.
Is the individual a minor (under 18 years old)?
*
Yes
No
If yes, please provide Parent/Guardian name and phone number.
Parent/Guardian Name (First, MI, Last):
*
Parent/Guardian Phone Number:
*
Please use format xxx-xxx-xxxx when entering phone number.
Are you scheduling the first dose or a booster?
*
First Dose (6 months-4 years old)
First Dose (5-11 years old)
First Dose (12+ years old)
Booster Dose
Is the individual a current patient at Randolph Community Clinic?
*
Yes
No
Thank you for registering for a COVID-19 vaccine.
We will call you soon with more information about your appointment.
Register
Home
About
Providers
Contact
COVID-19
COVID-19 Vaccine Information
COVID-19 Vaccine Registration
Telehealth
Resources