Covid-19 Vaccine Registry - 65 & Over

2. This registry is for information about vaccine availability for South Kingstown residents 65 and over.
   If you are 75 years of age or older and have already contacted the Town, please DO NOT register here. You will be contacted when vaccine is available. You will be required to present proof of identity and age at the time of vaccination. By registering here, you are providing the Town with your information that will be used to contact you IF a vaccine dosage is available for you at the municipal clinic.

   If you are 75 years of age or older and have already contacted the Town, please DO NOT register here. You will be contacted when vaccine is available. You will be required to present proof of identity and age at the time of vaccination. By registering here, you are providing the Town with your information that will be used to contact you IF a vaccine dosage is available for you at the municipal clinic.

4. Important Notice about availability of Vaccine:
   The State of RI is currently supplying each City/Town with an extremely limited number of doses each week and the Town has no control over this process. It may take several weeks or more before you are contacted to schedule your vaccination. The State may also change this procedure in the future so please check our web site Covid-19 page regularly.

   The State of RI is currently supplying each City/Town with an extremely limited number of doses each week and the Town has no control over this process. It may take several weeks or more before you are contacted to schedule your vaccination. The State may also change this procedure in the future so please check our web site Covid-19 page regularly.

6. First Name*

7. Last Name*

9. Address*

11. City*

12. State*

13. Zip Code*

15. Date of Birth*

    If you under 65 years of age, you are not currently eligible to register. Please enter in mm/dd/yyyy format.

16. Email Address*

18. Best contact Number*

    Please enter the area code and number.

19. Please select:*
    -- Select One --CellHome

21. Alternate Contact Information (Optional)
    If you wish to have an alternate contact person, please enter their information here.

    If you wish to have an alternate contact person, please enter their information here.

23. First Name

24. Last Name

26. Alternate Contact's Relationship to You

27. Alternate Contact Phone Number

29. Contact Email

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field