Vaccination Sign Up Form
‌(Phase 1C)

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

  • All adults aged 65-74
  • Persons aged 16-64 with underlying health conditions
  • Finance staff, including bank tellers
  • Information technology
  • Energy
  • Food services
  • Housing construction
  • Communications
  • Legal services
  • Public health workers
  • Public safety
  • Utility
  • Water and wastewater staff
  • Federal/state/county/local government

  • ‌Underlying Health Conditions ---

    ·         Cancer

    ·         Chronic Kidney Disease

    ·         COPD (chronic obstructive pulmonary disease)

    ·         Down Syndrome

    ·         Heart conditions

    ·         Immunocompromised state from solid organ transplant

    ·         Obesity (BMI of 30 or higher)

    ·         Pregnancy

    ·         Sickle Cell Disease

    ·         Smoking

    ·         Type 2 Diabetes

Note that at this time only the Pfizer-BioNTech product is approved for those age 16 and 17.

*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.