City of Berkeley COVID Vaccine Interest List

City of Berkeley COVID-19 Vaccine Interest List

Please fill out the form below
To sign up for email notifications about COVID-19 vaccination opportunities for the City of Berkeley, please visit bit.ly/berkvaccine

COVID-19 vaccines are in limited supply. We are currently vaccinating people 65 and older and healthcare workers in Berkeley who have not yet received the vaccine through their employer or their healthcare provider. As more vaccine becomes available, we will expand eligibility based on the State’s vaccine priority criteria.

Fill out this form if you have received specific instructions from Berkeley Public Health or COVID-19 Information Services. All responses will be kept confidential. We won’t share your personal information with anyone.

You will not be asked about immigration status in order to get a vaccine and you do not need health insurance in order to get a vaccine.
Please select an option from the following list, that best describes you*

I am a healthcare provider (with in-person patient contact)I am 75 + years oldI am between 65 and 74 years old
Name*

First NameLast Name
Email

Confirmation EmailPlease enter your email twice and make sure they match
I do not have an email address
Phone number*
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Race*
Ethnicity*
Do you have a primary medical provider?*

YesNoI don't know
Name of medical provider*
Do you have medical insurance?*

YesNoI don't know
Name of insurance company*
If you have a medical condition that increases risk of severe illness from COVID-19 or if you have a preferred contact method, please note it here
Should be Empty:

City of Berkeley COVID-19 Vaccine Interest List