Updated April 19, 2021

How to Request Access to the Free COVID-19 Vaccine Clinic in Nellysford

Questions? Special situation? Email vaccine@wtgfireresq.org

**This clinic is a Wintergreen Fire & Rescue effort in cooperation with the Blue Ridge Health District.**

Complete this form below to be put on the list to receive the COVID-19 vaccine in Nellysford. All adults are now eligible for the vaccine.

Follow these steps to register for upcoming clinics in Nellyford:

If you have already received your first dose of a COVID-19 vaccine, do not use this form.
If you are using one email address for two people, read and follow the special instructions where you enter the email address on the form below. (Using one email address per person is preferred.)

If you are providing this information on behalf of another person, CLICK HERE

* Asterisks mark those fields in the form below that are required.

Questions? Call 1-877-VAX-IN VA
1-877-829-4682

READ THIS: By checking below you are saying that you understand this is not making an official appointment; this form is only to create a list of interested individuals who will be notified if & when vaccines become available for this special area clinic. You also acknowledge that there are no guarantees that the vaccine will be available to you at these clinics and, if the clinic becomes active, the dates and location of the clinic may change.

Keep looking for other places to get your jab!

Got it. No guarantees. I'll keep looking for other opportunities to get vaccinated.

Your Name

First Name

Last Name

Your EMAIL address

NOTE: If this email address is shared with another person who also is signing up for this clinic, please note this–with their FULL NAME–at the end of this form under Special Considerations.

Phone number

The best number to reach you.

(###)

###

####

Date of Birth

This needs to match what is on your photo ID. (00/00/0000)

MM

DD

YYYY

Your Nelson County street address

OR, your Augusta County, Va., address within Wintergreen. (All others should contact their local health district office.)

City, State

ZIP Code

Your primary postal address, IF DIFFERENT FROM ABOVE

Otherwise, leave blank

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you registered to receive the vaccine with the Virginia Health Department (regional or state) ?

Special clinics are working in cooperation with the VHA. If you have not registered with the state yet, please do. Look for a link to the state's form on the page you see after you submit this form.

Yes. I have registered with the VHD.

No. I have NOT registered with the VHD.

Unsure / Don't know.

Special considerations

i.e.: health issues, school teacher, front-line essential worker, etc. (Please be specific. Otherwise leave blank.)

How to Request Access to the Free COVID-19 Vaccine Clinic in Nellysford

WINTERGREEN FIRE & RESCUE ADMINISTRATION ONLINE

Wintergreen Fire and Rescue, Po Box 711, Nellysford, VA 22958 USA • Phone 434-325-1051