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COVID-19 vaccine pre-enrollment form

Thank you for your interest in receiving the COVID-19 vaccine.

Only the following people are currently eligible to receive the COVID-19 vaccine at CHoR and should complete this form:

  • CHoR patients ages 12+
  • Parents/caregivers of CHoR patients

How to enroll

  • We are actively adding vaccine clinics to the schedule (as supply allows). Complete the form below and we’ll call you when a new vaccine clinic opens.
  • Parents/caregivers and children 12+ can register together on one form.
  • We are vaccinating up to two parents/caregivers per CHoR patient.
  • Note: Children under 12 are not yet eligible to receive the COVID-19 vaccine.