1. You must fill out ONE form for each person requesting a COVID-19 vaccination. DO NOT submit more than one person’s name on the form.
2. You must provide an accurate Phone Number. The Moultrie County Health Department (MCHD) will contact you BY PHONE ONLY when your appointment becomes available.
3. Please do not submit more than one form for the same individual. Multiple submissions or phone calls do not increase your opportunity for a COVID-19 vaccination appointment.
4. The MCHD will contact all Individuals who submit this form for a COVID-19 vaccine appointment in the order their request was received when doses become available.
5. If you previously submitted your name by phone to the MCHD and would like to submit this online form, please complete & submit the form only ONCE. If possible, please identify the date you previously submitted your name by phone in the NOTES section.
6. Please provide an email address in the space provided so that the MCHD can send you confirmation of your submitted form. A confirmation only means that the electronic system received your form. It does not confirm a vaccine appointment. The MCHD will schedule your vaccine appointment by phone.
7. If there are special considerations or other things you would like for us to know, please briefly state those concerns in the form’s NOTES section.
8. Every person who arrives for a vaccine will be required to provide proof of identity (driver’s license) and residency or work status in Moultrie County, Illinois.