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COVID-19 Vaccine Registry Form

THE HEALTH AND WELL-BEING of our community is our top priority. Tompkins County Health Department (TCHD) is working closely with community partners to prevent and respond to the evolving novel Coronavirus (COVID-19) outbreak.

Vaccine Icon -- Vaccines Protect Us All #7A015BAs eligibility and supply of the COVID-19 vaccine expands, the Tompkins County Health Department (TCHD) is continuing to plan an equitable rollout to residents. This registry is for TCHD to better understand demand for the vaccine and to communicate directly with those who are eligible to receive the vaccine when doses become available. Eligible individuals for this registry must live, work, or study in Tompkins County.

TCHD is encouraging 100% of those who are eligible to get the vaccine when they are able. Individuals should continue to seek available vaccine appointments through pharmacies and State-run sites if they are able. This registry does not replace those processes. Please continue to try to get the vaccination through other sites.

How this Information Will Be Used

TCHD will use this registry to distribute links (or call in the case of an individual not having computer access) for eligible groups to register for available vaccine appointments. This registry does not guarantee a vaccine appointment. This data will not be sold or used for any purpose other than what is stated within the form.

How to Use This Form

  • Enter your information below, accurately and truthfully.
  • Click all applicable criteria that make you are eligible for the vaccine.
  • When vaccine is available, you will be called/emailed to set up your appointment date/time based on the contact information you provide on this form.
  • Please do not call to ask where you are on the list, this is not a waitlist.
  • For individuals who do not have a computer or internet access, a friend, family member, or 211 can register the person and indicate that they do not have internet access. If this is indicated, the individual will receive a phone call when it is their turn for the vaccine.

TO REMOVE your name from the Registry, send an email to

Please subscribe to the Health Department's email list to receive more updates on Phases, vaccinations, and more.

Video: Registry Form Walkthrough

Watch this video to see step-by-step instructions for filling out the Registry form.

You can also watch the video on YouTube.

Register Here 

If your browser does not display the registry form below the line, please call 2-1-1 to provide the same information requested in the form. 

ERRORS CAUSE DELAYS! Please make sure your information is entered correctly before clicking submit!

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