Vaccine Pre-Registration for Educators (Updated 2.10.2021)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this pre-registration form to opt-in to COVID-19 vaccines. Once completed we will work to find appointments for vaccination. Please note there are limited numbers of vaccine slots and you will receive an email to set up your appointment.The time and date cannot be changed for the first round of vaccines.

Please Use your Work Email address below.

Email *

Re-type Your Work Email Address *

Personal Email Address

My District *

If Charter School Name

If Private School Name

First Name *

Last Name *

Have you participated in Santa Cruz COE COVID-19 Surveillance Testing at either Santa Cruz COE or PVUSD?

Yes

Not sure

Clear selection

I consent to be vaccinated for COVID-19. *

Yes

I have already been vaccinated

Clear form

Never submit passwords through Google Forms.

This form was created inside of Santa Cruz County Office of Education. Report Abuse

Forms