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COVID 19 Vaccine Interest Form for Campbell County Residents

  1. c19 vaccine cover
  2. Covid-19 Vaccine Interest Form for Campbell County Residents
    As the Virginia Department of Health continues to rollout COVID-19 vaccines, there may be opportunities for local residents to secure any unfilled appointment slots at our Public Safety Department's planned distribution sites for designated categories.
  3. Filling out the form below indicates your interest in receiving a vaccination should vaccine supplies and appointments happen to become available in the days ahead. As always, any vaccination opportunity coordinated by Campbell County is strictly voluntary and in alignment with the Virginia Department of Health guidelines and protocols.
  4. Please enter numeric characters only (no hyphens or parentheses).
  5. Please enter numeric characters only (no hyphens or parentheses).
  6. Please note:
    If you cannot be reached, you will remain on the list, however, the next person will be contacted to fill any vacant slot. If contacted, you will be provided with information on the time and location of your vaccination. You will also be expected to fill out medical paperwork in advance, which can be downloaded from this page prior to submitting this form. Also, please note that submitting this interest form does not guarantee a vaccination appointment, but rather places you on a list should one become available.
  7. Thank you for your submission. Be safe, Campbell!
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  9. This field is not part of the form submission.