Health and Community Services Department

Individuals 65 years and older Pre-Registration Form

This is a pre-registration form for individuals 65 years and older who are interested in receiving the COVID-19 vaccine. By submitting your information, you are placing your name on a waitlist with the health department. Do not complete this form if you are not 65 years and older and live in Kalamazoo county. Your name will be removed from the waitlist if you do not meet the age and county requirement.

If you are completing this form on behalf of someone (i.e. your parent or the person you are a guardian of), then be sure to enter an email address that will be most frequently checked. All other fields should be completed on behalf of the individual who is 65 years and older and lives in Kalamazoo county.

Please complete one form per eligible person. Please do not call the health department to confirm we received your form or when to expect your appointment. We are experiencing extremely high call volume. We encourage people to complete the online form so that the phone lines remain open to those who do not have a way to complete the form online or do not have technology to complete the form. We will notify you by using the preferred contact method you provided when we have vaccine supply and appointments available to schedule.

* Denotes required field

Please make sure your email address and phone number are entered correctly. This is how we will contact you to schedule an appointment. E-mail will be the quickest way to receive information.



Select your preferred time of day for a vaccine appointment. Please rank your 1st , 2nd and 3rd choice. (please note: we cannot guarantee accommodating your preferred time selected, but we will try. Your response will also help in planning and staffing vaccine clinics).

Are you a veteran? *    
Are you employed? *    
Do you have a primary care provider? *    
You have input errors you must correct before continuing. Please check all of the highlit fields above.

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311 E. Alcott St
Kalamazoo, MI 49001

269-373-5200

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Kalamazoo County Health & Community Services is committed to providing equitable, culturally competent care to all individuals served, regardless of race, age, sex, color, national origin, religion, height, weight, marital status, political affiliation, sexual orientation, gender identity, or disability. 

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