In-Home COVID-19 Vaccination Contact Form

The City of Evanston is working to reach all Evanston residents who are homebound due to medical conditions or are otherwise unable to attend the City’s COVID-19 vaccination events.

If you fit this criteria, please complete the form below so the City can coordinate in-home vaccination when the vaccine is available to you. (If you know someone who fits this criteria, please complete the form on their behalf.)

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* 1. Are you interested in receiving a COVID-19 vaccine?

Yes

Unsure

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* 2. Contact Information

Name *

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Age

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* 4. Are you an Evanston resident with a disability?

Yes

Prefer not to answer

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* 5. If yes, do you identify with any of the following disabilities?

Deaf/Hard of Hearing

Physical Disability

Mental Illness/Mental Health

Recovery/Addiction

Developmental Disability/Autism

Blind/Low Vision

Prefer not to answer

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* 6. Special Accommodations Required

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* 7. If you are submitting this form on behalf of someone else, please provide your contact information.

Name

Phone

In-Home COVID-19 Vaccination Contact Form

Question Title

* 1. Are you interested in receiving a COVID-19 vaccine?

Question Title

* 2. Contact Information

Question Title

* 3. Age

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* 4. Are you an Evanston resident with a disability?

Question Title

* 5. If yes, do you identify with any of the following disabilities?

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* 6. Special Accommodations Required

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* 7. If you are submitting this form on behalf of someone else, please provide your contact information.

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* 8. Other Comments