Skip to main content

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 the County's appointment notification list and a Dutchess County representative will contact you by phone or email when we can offer you a vaccine appointment opportunity at a County-sponsored vaccination site.

Additionally, you will receive weekly e-mail or text message updates about how many doses New York State is allocating to the Dutchess County Health Department as well as other area vaccine providers, such as pharmacies. Vaccine allocation information is also updated on the 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 the phone notification list.

If you have previously registered and need to correct or update information, simply complete this form again with your updated information.

If you would like to be removed from the notification list, please use our opt-out form to have your name removed so others on the list can be quickly notified of appointment opportunities.

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.

* Indicates a required field


*

*
*
*
*

*
(10-digit US phone number)

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


Date of Birth*

The Dutchess County Office for the Aging is assisting with booking appointments by phone for senior citizens and those without Internet access.

*
*
*
*
*
*

*

*

*

 

Required:


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.