Vaccination Sign Up Form
‌(Phase 1B)

Must be a Bucks County resident or employed in the county and one of the following:

  • All adults aged 75 and older

• First responders

• Correctional officers and other workers serving people in congregate care settings not included in Phase 1A
• Food and agricultural workers
• U.S. Postal Service workers
• Manufacturing workers
• Grocery store workers
• Education workers
• Clergy and other essential support for houses of worship
• Public transit workers
• Individuals caring for children or adults in early childhood and adult day programs

*These categories are general groups. For a more granular list of eligible positions please consult the DOH vaccine plan found here:
https://www.health.pa.gov/topics/Documents/Programs/Immunizations/
‌PA%20Interim%20Vaccine%20Plan%20V.4.pdf


*Additional vaccine guidance can be found at the Department of Health's website here:
https://www.health.pa.gov/topics/disease/coronavirus/Pages/Vaccine.aspx

Vaccination Sign Up Form for Individual

**Each Household Member Requires 
‌Separate Submission.