**For assistance call the state’s COVID-19 hotline: 877-829-4682**

Request access to the Special COVID-19 Vaccine Clinic for another person living in the Wintergreen area (65-years-old or older)

It is much better if everyone wanting to be on this list for this clinic sign up themselves using this form. Don’t use this form here casually.

But, if you see a need to sign up someone besides yourself for this local clinic (nearby family member, neighbor, local friend,…) and you have their permission, you can use our form here to have them be put on the list to receive the COVID-19 vaccine in Nellysford. (Note the restrictions stated in the form below.)

This effort is being coordinated by Wintergreen Fire & Rescue in cooperation with the Blue Ridge Health District.

*Marks fields in the form below that are required.

The name and phone number of the person who is completing this form:

Also, a brief note here about why you are assisting would be helpful.

You MUST have permission of the person whose information you are providing below. 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 the person named below and, if the clinic becomes active, the dates and location of the clinic may change.

We appreciate your patience and understanding.

I have read the terms outlined here.

Name of the applicant

First Name

Last Name

Their EMAIL address

Do not enter your own email address here.

Phone number of applicant

The best number to reach you.

(###)

###

####

Date of Birth of applicant

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

MM

DD

YYYY

Their Nelson County street address

Those outside of Nelson County, Va., should call the state’s COVID-19 hotline: 877-829-4682

City, State

ZIP Code

Their primary postal address, IF DIFFERENT FROM ABOVE

Otherwise, leave blank.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have they 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.)

Request access to the Special COVID-19 Vaccine Clinic for another person living in the Wintergreen area (65-years-old or older)

WINTERGREEN FIRE & RESCUE ADMINISTRATION ONLINE

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