COVID-19 Vaccination

First Name*

Last Name*

Date of Birth*

Postal Code*

Email Address*

Phone*

Health Care Card*

Street Address*

City*

Province*

Postal Code*

Self Identification Questions

Eligibility is set by AHS (Alberta Health Services) and may be dynamic as vaccine becomes available. This will help us identify you based on eligibility criteria.

Occupation

Are you a Healthcare Worker or Essential Caregiver?*

(e.g. physician, nurse, LTC/supported living/retirement home care worker, paramedic, pharmacist, staff, family caregiver or employee in congregate living setting, etc.)

Yes

Are you a Frontline Essential Worker?*

(e.g. first responder, educator, food & agriculture worker, manufacturing, corrections worker, postal service worker, public transit worker, grocery store worker, migrant worker, food service employee, etc.)

Yes

Additional Questions

Do you identify as an Indigenous Canadian (First Nations, Métis, Inuit, or other designation)?*

Yes

Do any of the following apply to you?*

- I have experienced homelessness in the past 30 days - I live in a shelter

Yes

Does your place of residence qualify as any of the following?*

- Congregate or overcrowded living setting - Isolated or remote community

Yes

Are you pregnant, breastfeeding, or planning to become pregnant? *

Yes

You have a chronic medical condition (i.e. diabetes)*

Yes

You have a weakened immune system due to a medical condition/medication*

Yes

You live with someone who has a chronic medical condition*

Yes

Do you have any of the following?*

- Missing spleen or a spleen that is no longer working
- Cancer (anyone with a new diagnosis of or treatment for all forms of cancer in the last year, except non-invasive skin cancer)
- Chronic heart disease and vascular disease (Including: congenital heart disease, chronic heart failure, heart or kidney disease from high blood pressure, and a history of a stroke BUT not including high blood pressure alone)
- Chronic kidney diseases requiring regular medical monitoring or treatment
- Chronic liver disease due to any cause
- Chronic neurological disease (including Parkinson’s disease, muscular dystrophy, MS, and dementia)
- Chronic lung diseases (including chronic obstructive pulmonary disease (COPD), cystic fibrosis, pulmonary hypertension, and severe asthma requiring hospital visit in last year. BUT not including mild or well-controlled asthma)
- Diabetes requiring insulin or other medication
- Weakened immune response due to disease or treatment including chemotherapy or treatment for HIV, genetic disorders of the immune system, people receiving long-term medical treatment to control severe inflammation (e.g. rheumatoid arthritis)
- Severe mental Illness or substance use disorder requiring a hospital stay during the past year (eg. schizophrenia, depression, anxiety disorders, etc.)
- Severe obesity (Body Mass Index of >40 kg/m2)
- Severe or profound learning disabilities or severe developmental delay (including individuals with Down syndrome, Fetal Alcohol Spectrum Disorder, cerebral palsy, autism spectrum disorder, etc. but not including: Attention Deficit Hyperactivity Disorder (ADHD)
- Solid organ, bone marrow or stem cell transplant recipients

Yes

This field should be left blank

Self Identification Questions

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