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COVID-19 Vaccine Information
COVID-19 Vaccine Registration
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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.
Is the individual a current patient at Randolph Community Clinic?
*
Yes
No
We are following the guidance of the
Wisconsin Department of Health Services
and are currently only able to administer vaccines to our patients who meet eligibility based on their age or risk category.
Click here
for more information about qualifying "high risk health history."
Please select the category which applies to you (select one):
*
1A - Health care worker or Resident of Long Term Care facility
1B - Police, Fire, Correctional staff
1B - Adult 65 years of age (or older)
1B - Educator, Teacher, Child care provider
1B - Medicaid Long-term care program, congregate living staff or resident
1B - Public-facing essential worker (911 operator, Utility and communications, Public transit, Food supply chain)
1B - Non-frontline essential health care personnel
1C - Individual with Underlying Health Conditions (high risk health history such as cancer, diabetes, COPD, heart disease, smoking, obesity, kidney disease, immune condition, Down syndrome, pregnancy, sickle cell disease)
2 - General Population 16 years of age (or older)
3 - Child 12-16 years of age
3 - Child 0-12 years of age
Register
Home
About
Providers
Contact
Telehealth
COVID-19
COVID-19 Vaccine Information
COVID-19 Vaccine Registration
Resources
