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COVID-19 Interest Forms

If you are interested in receiving the COVID-19 vaccine, please complete the appropriate interest form, below. This is NOT a registration form. We are prioritizing vaccination for people who live and/or work in Carroll County, Maryland. 

We are not currently able to contact everyone as soon as they submit a form. Please be assured that we receive all forms and are monitoring our interest lists.

Please complete the appropriate form for each person who is interested in receiving the vaccine. If you need assistance completing the form, please call our call center at 410-876-4848, open Monday-Friday, 8 am – 5 pm. Please be patient. We are experiencing an extremely high volume of calls.

Please make sure you are filling out the correct form. For more information on who is in each phase, visit the Maryland Department of Health’s vaccine page. You will need to bring a photo ID and proof of eligibility to vaccination clinics.

We currently have the Moderna vaccine at the Carroll County Health Department and the Moderna vaccine can only be offered to individuals ages 18+.

The Carroll County Health Department (CCHD) cannot provide any medical advice regarding whether or not you should receive the vaccine. You should talk to your healthcare provider before signing up to receive the vaccine.  The CCHD reserves the right to decline to vaccinate any individual we do not feel safe vaccinating, as we have limited medical support services on site. For CDC information on underlying health conditions and COVID-19 vaccination: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/underlying-conditions.html

 

Phase 1A: If you are a health care provider, law enforcement officer, or first responder in 1A, and you live or work in Carroll County, OR

Phase 1B: If you work at a private school, childcare agency, or higher education institution in Carroll County:

Please contact Jennifer Stewart at jennifer.stewart1@maryland.gov for assistance in registering for the next available vaccination clinic.

You are eligible to be vaccinated at other sites and may want to try to find an appointment through retail pharmacies, large clinics, or the state’s mass vaccination sites: https://coronavirus.maryland.gov/pages/vaccine#locator

 

If you are age 65+ and still need your first dose of the COVID-19 vaccine, please call 410-876-4848. We will work to get you registered for an appointment.

 

Carroll County residents with intellectual or developmental disabilities (1B)

Marylanders ages 16+ with disabilities who are receiving SSI or SSDI benefits, Maryland Medicaid EID individuals, Maryland Medicaid REM recipients, and Marylanders receiving TDAP benefits (2B)

Marylanders receiving long term services and supports through the state’s Medicaid waiver and state plan services (learn more) (2B)

Please email Jennifer Stewart at jennifer.stewart1@maryland.gov for assistance in registering for vaccination. You may also call the call center at 410-876-4848 for assistance.

 

NEW! Vaccination Interest Form for Carroll County residents age of 60-64 (2A)

Please click the link above and complete one form for each person who is between the ages of 60-64.

If you are unable to complete the form online, consider asking a friend, neighbor or family member for assistance or call our call center at 410-876-4848.

 

Vaccination Interest Form for Carroll County residents age 18-64* with health conditions that increase risk of serious illness from COVID-19 (see CDC list). (Phase 2B)

Please click the link above and complete one form for each person who has one of these health conditions and is interested in being vaccinated.

If you are unable to complete the form online, consider asking a friend, neighbor or family member for assistance or call our call center at 410-876-4848.

Please note: You WILL NOT receive an appointment after completing the survey. We will contact you when we are able to register you for a vaccination appointment.

*Please note that though eligibility extends to people 16 and up, the Health Department is currently only offering Moderna at our clinics, and the Moderna vaccine is only approved for 18+.

 

Vaccination Interest Form for Essential Workers in Carroll County (1C, 2C)

Please click the link above and complete one form for each person who is interested in receiving the vaccine and is an essential worker who lives or works in Carroll County and is working in person (not teleworking). Please note that the state of Maryland currently has essential workers in Phase 1C and Phase 2c. 1C includes:

    • Public safety
    • All other healthcare (lab services, vaccine manufacturing, other healthcare)
    • Food and agriculture production
    • Critical manufacturing
    • US Postal Service
    • Public Mass Transit
    • Grocery stores or grocery section of larger stores
    • Veterinarians and support staff
    • Clergy and essential support staff
    • Legal professionals
    • Members of the media

2C includes essential workers in critical industries, including construction workers, food services, utilities, transportation, financial services, IT and other infrastructure (opens April 13th).

If you are unable to complete the form online, consider asking a friend, neighbor or family member for assistance or call our call center at 410-876-4848.

Please note: You WILL NOT receive an appointment after completing the survey. We will contact you when we are able to register you for a vaccination appointment.

 

Vaccination Interest Form for Carroll County – General Population

If you are unable to complete the form online, consider asking a friend, neighbor or family member for assistance or call our call center at 410-876-4848.

Please note: You WILL NOT receive an appointment after completing the survey. We will contact you when we are able to register you for a vaccination appointment.

Please complete a separate form for each person who is interested in receiving the vaccine and that do not fall in to any priority groups: https://forms.gle/hRUHkbY3gdyVesh66