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Canton Township COVID-19 Individual Vaccine Waitlist

2. Thank you for your interest in the COVID-19 vaccine waitlist. Please note that completion of this form, does NOT guarantee a vaccine for you. Please complete the set of questions. If you are eligible, you will be contacted as soon as a vaccine appointment is available for you. Please note we will be requesting proof of eligibility at time of vaccination, and are only vaccinated those aged 65 or older at this time. If you are not yet eligible, you will need to check back later with the Wayne County Public Health Department (www.waynecounty.com/covid19) Unfortunately, there is not enough vaccine available at this time to vaccinate everyone.

   Thank you for your interest in the COVID-19 vaccine waitlist. Please note that completion of this form, does NOT guarantee a vaccine for you. Please complete the set of questions. If you are eligible, you will be contacted as soon as a vaccine appointment is available for you. Please note we will be requesting proof of eligibility at time of vaccination, and are only vaccinated those aged 65 or older at this time. If you are not yet eligible, you will need to check back later with the Wayne County Public Health Department (www.waynecounty.com/covid19) Unfortunately, there is not enough vaccine available at this time to vaccinate everyone.

4. Please continue to seek other vaccination options, with health care systems, and local pharmacies, and take the first available to you.

6. Do you live in Canton Township, Plymouth Township, or City of Plymouth?*

   1. Yes
   2. No

   Please note: At this time we are only vaccinating those that live in Canton Township, Plymouth Township, or the City of Plymouth. ID will be checked upon entry, prior to receiving your vaccine to confirm your eligibility.

8. Are you 65 years of age or older?*

   1. Yes
   2. No

   Please note: At this time we are only vaccinating those 65 years of age or older. ID will be checked upon entry, prior to receiving your vaccine to confirm your eligibility

10. What is your first name?*

12. What is your last name?*

14. What is your zip code?*

16. Please enter your email address

18. Please verify your email address

20. What is your phone number (Enter numbers only with no dashes or special characters. Example: 7340000000) *

22. Thank you for filling out this survey. After you press submit, we will place your contact information in a queue, and will contact you if there is a vaccine appointment for you, based on the availability of vaccines from Wayne County Public Health. This information will added to a vaccine waitlist. If an appointment becomes available, we will contact you. You will receive further details via email regarding your scheduled vaccine appointment. Please be patient and know we have received your survey.

    Thank you for filling out this survey. After you press submit, we will place your contact information in a queue, and will contact you if there is a vaccine appointment for you, based on the availability of vaccines from Wayne County Public Health. This information will added to a vaccine waitlist. If an appointment becomes available, we will contact you. You will receive further details via email regarding your scheduled vaccine appointment. Please be patient and know we have received your survey.

24. Wayne County Public Health Division COVID-19 Vaccination Information
    Wayne County COVID-19 Vaccine Info

    For more information on the COVID-19 vaccination distribution in Wayne County, please visit the Wayne County Public Health Division's website link above

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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field