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Posted on: February 24, 2021

COVID-19 VACCINATION INFORMATION FORM

The Village of Midlothian is diligently seeking COVID 19 vaccine opportunities to assist senior residents 65+. In the event we receive information on vaccine opportunities, we will notify seniors via email. The submission of the form does not guarantee access to the vaccination.

IMPORTANT INFORMATION- PLEASE READ:

  • Completing this form DOES NOT guarantee access to the vaccination
  • Completing this form will allow the Village to notify you, by email, of vaccine opportunities the Village becomes aware of
  • You must have an email address to receive notice
  • Only senior's and resident of Midlothian will receive notice
  • At this time, Village staff does not have any additional information


Complete and submit form online

Print form

COVID19_Form

Complete and submit form online

Print form

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