If you do not want the vaccine,
or you will be offered the vaccine through your employer,
you do not need to complete this form.

How Do I get my vaccination?

We will be receiving our Vaccinations from Riverside.

We have to collect information about those interested in receiving the vaccine and provide that information to Riverside. They will then enter you into their system so you can call to schedule the vaccination appointment. Below is a step by step process to get your vaccination:

  1. READ THIS FIRST -> Riverside Vaccine Infographic
  2. Complete and submit the form below (information will be sent to Lewis Kerns).
  3. Your information will be provided to Riverside the next business morning
  4. After noon on the business day after you submit this form, call the number on the infographic above to schedule your appointment. I will also let you know that your information has been passed along and when to call.
  5. Let Lewis Kerns know once you have scheduled your vaccination so I can keep track
  6. You need to provide a copy of your vaccination paperwork to Karen Kramer once you have received your shot

If you previously completed the request form on this page, Riverside has your name and contact, but they need your date of birth. If you will forward that to me, I’ll pass it along.


To add your name to the list, please complete this form. This information will be emailed to Lewis Kerns, then passed along to Riverside.