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COVID-19 Vaccine Survey Form for Seniors

  1. The Town of Madison, CT is collecting information from residents age 65 and up who would like to be notified when the COVID-19 vaccine is available. By registering with us, we can quickly and accurately update you as information becomes available.

  2. Please sign up ONE time per person. Thank you.

  3. Please acknowledge:*

  4. Please enter in MM/DD/YY

  5. This information may be shared with the VAMS system.

    VAMS is the State of Connecticut Vaccine Administration Management System

  6. Phase 1a

    Healthcare Personnel, Long Term Care Facility Residents, Medical First Responders

  7. Phase 1b

    Front line essential workers, individual and staff in congregate settings, individuals 75 years of age and older

  8. Future Phases

    COVID-19 vaccinations will be available to eligible members of the general public starting this summer.

  9. If you are having difficulty using the online form, please contact the Madison Senior Center at (203) 245-5627 for assistance.

  10. More Information

    After you submit this form we will re-direct you to the State of Connecticut COVID-19 Response website so you can read more about the State's plans. https://portal.ct.gov/Coronavirus/COVID-19-Vaccination---Phases

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  12. Thank you for your information.

    Please click the submit button below the email address field.

  13. Leave This Blank:

  14. This field is not part of the form submission.