COVID-19 Vaccine Registration

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: *

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: *

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.