2. This is a Registration Form only, not an Appointment.
   This form will allow people who live in Lawrence to register for a COVID-19 vaccination through the City of Lawrence. The City's ability to hold vaccination clinics is dependent on vaccine availability. If you can access the vaccine through other means, you should do so. Once you have registered you will be added to our waitlist. The City will follow the State’s prioritization process for vaccines. Once the City receives its vaccine doses from the State, health officials will set up clinics in City. We will call people on a first-come, first-served based on prioritization with instructions to schedule your vaccine appointment.
4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address
10. Do you live in The City of Lawrence?*

    1. Yes
    2. No
12. Address
13. Zip Code
15. What Phase Do you Qualify For?
17. Phase 1

    (December 2020 – February 2021) Listed in order of priority:

    1. Clinical and non-clinical health care workers doing direct and COVID-facing care
    2. Long term care facilities, rest homes and assisted living facilities
    3. First responders
    4. Congregate care settings
    5. Home-based health care workers
    6. Health care workers doing non-COVID-facing care
19. Phase 2 Group 1:

    1. Individuals age 75+
21. Phase 2 Group 2:

    1. Individuals age 65+
    2. Individuals with 2+ certain medical conditions
    3. Residents and staff of low income and affordable senior housing
23. Phase 2 eligible conditions:

    1. Cancer
    2. Chronic kidney disease
    3. COPD (chronic obstructive pulmonary disease)
    4. Down Syndrome
    5. Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
    6. Immunocompromised state (weakened immune system) from solid organ transplant*
    7. Obesity and severe obesity (body mass index [BMI] of 30 kg/m2 or higher)
    8. Pregnancy
    9. Sickle cell disease
    10. Smoking
    11. Type 2 diabetes mellitus
    12. Asthma (moderate-to-severe)
25. Phase 2 Group 3: Other workers, including:

    1. Transit, grocery, utility, food and agriculture, restaurant and cafe workers
    2. Teacher/Staff in K-12 Schools, Early education/daycare
    3. Employees across the food, beverages, agriculture, consumer goods, retail, and foodservice sectors;
    4. Meatpackers;
    5. Sanitation, public works and public health workers;
    6. Vaccine development workers;
    7. Food pantry workers and volunteers;
    8. Transit/transportation: Uber/Lyft/ride share services/pharmacy delivery drivers, airline workers, workers in the passenger ground transportation industry (e.g. paratransit for people with disabilities
    9. Convenience store workers (under grocery workers);
    10. Water and wastewater utility staff
    11. Court system workers (judges, prosecutors, defense attorneys, clerks), other than court officers who are listed under first responders
    12. Medical supply chain workers
    13. Funeral directors and funeral workers
    14. Shipping port and terminal workers
27. Group 4: Individuals with one certain medical condition

    1. Cancer
    2. Chronic kidney disease
    3. COPD (chronic obstructive pulmonary disease)
    4. Down Syndrome
    5. Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
    6. Immunocompromised state (weakened immune system) from solid organ transplant*
    7. Obesity and severe obesity (body mass index [BMI] of 30 kg/m2 or higher)
    8. Pregnancy
    9. Sickle cell disease
    10. Smoking
    11. Type 2 diabetes mellitus
    12. Asthma (moderate-to-severe)
29. Phase 3 (Starting April 2021)

    If your group is not specifically listed in either Phase 1 or Phase 2, you will be eligible to receive the vaccine in Phase 3, which we expect to launch in April. The vaccine is expected to be available to the general public, including:

    1. Higher education workers, including administrators, teaching and non-teaching staff;
    2. Bottled beverage industry workers;
    3. Veterinarians
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

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