Adult H1N1 Influenza Vaccine Interest Form: Please complete this form to let the Town of Somers know you would be interested in receiving the H1N1 Flu Vaccine at a Town-sponsored clinic. You must be a resident of Somers to participate.
You will be contacted as vaccine becomes available and public clinics are scheduled in the order that these Adult H1N1 Vaccine Interest forms are received.
* Information is required.
Contact Information
Check here to have email confirmation of this request sent.
* Information is required.
Notes:
Thank you for your responses. You will be contacted when doses of vaccine are received and a public clinic is scheduled.
Because we have required you to include your e-mail address on your response, you'll receive a Tracking Number allowing you to view your response.
Internal Use Only, Leave Blank:
Please leave this field blank and remove any values that have been populated for it.
