This is a COVID-19 Pre-Registration Survey. If you have already completed a survey for pre-registration, please still complete this survey as it will allow us to update our database and ensure we are vaccinating everyone in a timely manner. If you have already pre-registered to receive the COVID-19 vaccine through the Benzie-Leelanau District Health Department, the date of your initial pre-registration will be maintained. We will use the information provided in this survey to update our records.
Please note that if you are filling out this survey for a family member or friend, complete the form with the family member/friend’s name, their date of birth, and their residence. Please use the preferred phone and email contact information for scheduling.
If you are registering as an individual, please fill out a new survey for each person you are pre-registering for the COVID-19 Vaccination.
If you are a Business and have employees that fall into multiple priority categories, please fill out a new survey for each priority category you are pre-registering for the COVID-19 Vaccination.
By completing and submitting this survey, I am acknowledging that I agree the information I provide will be utilized for the purpose of scheduling a COVID vaccination appointment through the health department and/or other assisting partners.