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Vaccination Information Request Form

This form gathers contact information for individuals wishing to receive the COVID-19 vaccine as supply is available. Individuals must be eligible in phases defined by New York State [See if you are in a qualifying group].

This form does not pre-register you for a COVID-19 vaccination appointment. After you fill out the Vaccine Information Request form, your information will be added to a County notification list, and you will receive email or text message updates from Dutchess County about when and where appointments may be available, including how to register for an appointment at a County-sponsored vaccination site.

Vaccine allocation information is also updated on County's website at www.DutchessNY.gov/COVIDVaccine

Individuals without internet access should call the Dutchess County Coronavirus Information Line at 845-486-3555 to receive vaccine updates by phone and to be added to phone notification list.

Please note: The information you submit is for the sole purpose of gathering contact information to provide public outreach regarding COVID-19 vaccine. The information submitted on this form will not be disseminated to any outside entity other than Dutchess County Government. All information you submit remains private.

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(10-digit US phone number)
(10-digit US phone number; SMS / Text message and data rates may apply)


Date of Birth*

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If Yes, you will be added to the Dutchess County Office for the Aging’s notification list for available appointments.

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By clicking the Submit button below, I consent to be contacted by Dutchess County regarding COVID-19 vaccine information, and I consent to be subscribed to Dutchess Delivery for e-mail or text message notifications and updates.