Individual Registration

Are you interested in receiving the COVID-19 Vaccine?

Based on availability, and with guidance from the Pennsylvania Department of Health (PA-DOH) and the Centers for Disease Control (CDC), the County of Fayette (PA), will be assisting our partner providers in gathering information from those who are eligible and would like to receive the COVID-19 vaccine.

Vaccinations will be available by appointment only at this time. Eligibility is determined by the PA-DOH and CDC guidelines. Once the vaccine is available, provider partners will use your information from the survey below to contact you with further instructions. Per the guidance provided by the CDC, COVID-19 vaccinations will not be provided to those under the age of 16.

Submitting your information in this survey will place you in the Fayette County registry database. PLEASE SUBMIT THE INFORMATION FOR YOU (AND ANY OTHER HOUSEHOLD MEMBERS WHO ARE ELIGIBLE) ONLY ONE TIME. DUPLICATE ENTRIES WILL BE DISCARDED.

Consent for information

I hereby authorize the County of Fayette to collect, store, and manage the data I have disclosed on this registry. I further authorize the County of Fayette to permit access to the data by partner hospitals, clinics, and pharmacies in the COVID-19 Vaccine Taskforce in the effort to provide vaccinations to all who request them. I do not authorize any other use of this data.

Click here to begin filling out the questionnaire