Sign-Up – SETROC

COVID-19 Vaccination Sign-Up

Please fill out the form below to sign-up for the COVID-19 vaccination.
THIS IS NOT AN APPOINTMENT
After your registration has been completed, you will be able to schedule through your profile.

Note: If your application recognizes your submission as spam, please fill out the application without auto-fill.

User Registration

Vaccination Location *

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Ethnicity *

Race *

Opt-out of using e-mail address to register account?

No Yes

Email Address *

You may register and schedule without an email address, but will be unable to access advanced online features and will have one less method of contact/notification.

Phone *

Address *

Address

Suite/Apt #

City

State

Zip

Vaccine Administration

If you are human, leave this field blank.