By completing the below form, you are attesting that you meet your state’s current vaccine eligibility criteria. See a full list of Kansas’ Phase 1 and 2 eligibility.

COVID-19 vaccine wait list sign-up

Required fields are marked with an asterisk *.
I have reviewed my state's eligibility criteria, and I attest that I am currently eligible to receive a COVID-19 vaccine *

If you do not have an email address, please write N/A

NOTE: Each person in a household must complete a separate form to request a vaccine. If you’d like to request an appointment time with another member of your household, please indicate it in the comment section below. We will make every effort to schedule appointments together.


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