Translate

Lee County Government Health Department COVID-19 Registration Form

You have accessed the COVID-19 Vaccine Pre-Registration Form for the Lee County Government Health Department (LCGHD). Completing this form initiates the registration process; this does not complete the registration process, confirm eligibility, or act as a sign-up for the next county vaccine clinic. By completing and submitting this form, you are indicating your interest in being vaccinated by LCGHD and consent to contact from LCGHD staff by phone and/or email to verify eligibility and complete the registration process.

All individuals 16 years of age and above are now eligible to recieve their COVID-19 vaccination.

Individuals in the age ranges of 5 to 11 years and 12 to 15 years are eligible for vaccinations provided they meet verification requirements such as parent/guardian authorization, phone call verification, and proof of identification.

Individuals that complete this pre-registration form should expect to see a thank you page and submission receipt upon successful completion of this form. If your submission is successful, please do not call the LCGHD registration phone lines or submit multiple registration forms for a single individual – duplicate entries may incur additional processing time to verify information. A staff member will contact you to verify eligibility and complete your registration if you are eligible to be vaccinated under current guidelines.

Thank you in advance for your cooperation and patience as we move forward with vaccinating the Lee County community.

What is the age range of the person being registered?

Please proceed in completing this form

Please do not proceed completing this form, this form is for people 5 years of age and older. If you are not at least 5 years of age and you choose to continue completing and submit this form it will not be processed and you will not recieve any further communciation from the Lee County Health Department regarding this registration.

You are seeing this message because you have noted that you are between the ages of 12 and 15. In order for this pre-registration to be processed, you must have your Parent or Legal Guardian sign this form at the bottom of this page. You must also input their phone number below this message.

You are seeing this message because you have noted that you are between the ages of 5 and 11. In order for this pre-registration to be processed, you must have your Parent or Legal Guardian sign this form at the bottom of this page. You must also input their phone number below this message.

Phone Number of Parent or Legal Guardian giving authorization to children between the ages of 12 and 15.

Phone Number of Parent or Legal Guardian giving authorization to children between the ages of 5 and 11.

Registrant's Phone Number

Additional Comments

Signature of Parent or Guardian for children between the ages of 5 and 15. By signing here, you the Parent or Legal Guardian of the registrant of this form, are giving legal authorization for the child between the age of 5 and 15 that you are legally responsible for to register and receive the COVID-19 vaccination. A verification call will be made via the call center and final verification may be made at the time of the vaccination event. Valid proof of identification will also be required at the vaccination event for those 5 to 15 years old. (IF YOU ARE OVER THE AGE OF 16, THIS SIGNATURE PROVIDES AUTHORIZATION FOR YOU TO REGISTER AND RECIEVE THE COVID-19 VACCINATION)

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.