Vaccine Interest Form for Ashland Residents 65+

This form is now closed. Now that vaccines are widely available, Ashland Senior Services Division is no longer maintaining an interest list. However, if you are having difficulty accessing a vaccine, call us at 541-488-5342 for navigation assistance.
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Ashland Senior Services Division is maintaining a list of seniors seeking the COVID-19 vaccine. If you are an Ashland resident 65 years or older please fill out the form below. As vaccine appointments arise at various local clinics, we will contact the people on our list.
Update: As of 3/29/21, Ashland residents age 45-64 with an underlying condition are also eligible and may sign up on this list.

Jackson County seniors and people with disabilities who live outside of Ashland should call the Aging and Disability Resource Connection (ADRC) at 541-618-7572 to get on their list instead. We are working together, so there is no need to get on both lists.

* NAME

* BIRTHDATE (Please enter as mm/dd/yyyy. Please do not sumbit this form unless you are 65+ or 45-64 with an underlying condition.)

* PHONE

* STREET ADDRESS

* CITY

EMAIL (if available)

* DO YOU HAVE TRANSPORTATION TO AND FROM THE VACCINE APPOINTMENT? (Mark No if you need help with transportation)

Yes

* CAN YOU ATTEND AN EVENING APPOINTMENT?

Yes

* CAN YOU ATTEND A WEEKEND APPOINTMENT?

Yes

* WOULD YOU WANT AN APPOINTMENT OUTISDE OF ASHLAND, IF AVAILABLE?

Yes

* DO YOU GIVE APRC PERMISSION TO SHARE YOUR INFORMATION CONFIDENTIALLY WITH ANOTHER AGENCY THAT IS DOING THE SCHEDULING OR VACCINATING?

Yes

NOTES (optional): Note here if you have an underlying condition or other special needs.

Thank you for completing the COVID-19 Vaccine Interest Form. Due to heavy volume, please do not call for updates. You will be contacted when an opening for you becomes available.

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COVID-19 Vaccine Interest Form

Vaccine Interest Form for Ashland Residents 65+

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