COVID-19 Vaccine Registration

COVID-19 Vaccination Request

NOTICE: THIS FORM IS A REQUEST TO BE PLACED ON OUR WAITLIST, IT DOES NOT REGISTER OR GUARANTEE YOU AN APPOINTMENT!

Completing this online form is a request to be placed on the Town of Melbourne Beach COVID-19 vaccination waitlist. As part of the Beachside Strike Team, the Town of Melbourne Beach is working with other local municipalities to set up a drive-through Vaccine Distribution Point. The information submitted on this form will be used to create a list of people interested in obtaining a vaccination, and once doses become available, you will be contacted directly to verify your eligibility criteria and set up an appointment date and time.

If we are unable to reach you, or if you are unable to make the date and time we have available for your appointment, you may be bumped back to the end of the list.

Completion of this form does not guarantee you an appointment or a COVID-19 vaccination; it is also not the same as pre-registering with the State of Florida, which we recommend you complete in addition to this form.

Due to the ever changing nature of this health crisis, it is strongly suggested that you continue to try to obtain a vaccination on your own through other available sources.

People currently eligible to be placed on our Waitlist:

Florida residents that are 65 years of age or older.
Florida residents that are frontline healthcare workers with direct patient care.
Residents and Staff of long-term care facilities located in the State of Florida.
Florida K-12 school employees that are 50 years of age and older.
Florida sworn law enforcement officers that are 50 years of age and older.
Florida firefighters that are 50 years of age and older.

WAITLIST REQUEST FORM

Eligibility Criteria of individual requesting COVID-19 Vaccination*

Select an option from the drop down box below.

Name of individual requesting COVID-19 Vaccination*

First & Last Name

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Location of individual requesting the COVID-19 Vaccination*

City and State of Residence

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Is the individual requesting COVID-19 Vaccination homebound?*

Select an option from the drop down box below.

Who is completing this registration form?*

Select an option from the drop down box below.

Primary Contact's Name*

First & Last Name

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Primary Contact's Phone Number*

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Primary Contact's Email Address

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Acknowledgment*

I confirm that I have already reviewed all of the documentation related to the vaccine and I am an eligible candidate for the vaccination.

I understand that submitting this form does not guarantee me a vaccination or appointment.

I understand that I should continue to try to get the vaccination elsewhere.

I understand that the information submitted on this form will be used to create a waitlist, which may be used in the future to schedule vaccination appointments if/when they become available.

I understand that any information I submit on this form is sent to the Town of Melbourne Beach and may become public record.

COVID-19 Vaccination Request

WAITLIST REQUEST FORM

Your registration has been submitted

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