Vaccination Notification Request Form

The purpose of this form is to gather contact information for individuals wishing to receive the COVID-19 vaccine as it becomes available.  Currently, the COVID-19 vaccine is being rolled out to specific groups in phases defined by the New York State Department of Health [See if you are in a qualifying group].

This is not to pre-register for a COVID-19 vaccination appointment. After you fill out the Vaccine Notification Request form, your information will be added to a County mailing list, and you will receive email updates from Greene County as to when you may be eligible to receive the vaccine, including on how to register for an appointment.

At this time, only persons who qualify under Phase 1b (including Seniors Aged 65+ and persons with co-morbidities) should fill out and submit the on-line COVID Vaccination Notification Request Form.

For Seniors Aged 65+

Currently, Seniors can only receive vaccines through authorized Pharmacies and Health Care Providers.  Should vaccines become available to the county to inoculate Seniors directly, this list will enable us to communicate quickly to all who have signed up. Greene County will continue to advocate for better access for Seniors through communications with NYS and local vaccine providers.  As additional information becomes available, Seniors on this list will receive notification by eMail or phone.

Please note: The information you submit is for the sole purpose of gathering contact information to provide public outreach for the COVID-19 vaccine. The information submitted on this form will only be used for COVID-19 vaccine purposes. The information you submit will remain private.


    *You may select multiple reasons for wanting the vaccine. On a phone, please tap all that apply. On a computer, please hold Ctrl while clicking all that apply.

    Persons with Comorbidities and Underlying Conditions Must Provide a Doctor's Letter or Medical Information Evidencing Comorbidity or A Signed Certification as Determined by Greene County.