San Benito County

Health & Human Services Agency

Hollister, California

COVID-19 Vaccine Interest Form

Thank you for keeping our community safe! We are glad that you are interested in receiving a COVID-19 vaccination. Once you complete and submit the online form and we will add you to a contact list so that we can reach out to you as each Phase 1b progresses. For additional information about the different Vaccination Tiers, please visit the following page from the State of California:

Filling out this form will put you on the contact list for vaccines. This is not scheduling your vaccine appointment. That will come later, as each Phase and Tier becomes eligible. 

This form is to be completed for individuals that live or work in San Benito County who are ages 16 and above and are identified only in Phase 1B Tier 1 and 2 of the vaccination plan.  The State will be rolling out a system for those identified in a later group which is anticipated in the coming week.

If you do not live or work in San Benito County, please do not complete this form.

Language Translation Disclaimer
Best viewed withGoogle Chrome and Firefox. Our Agency’s website links to Google Translation as a convenience for those who speak/read languages other than English.  Please be aware that no automated or computerized translation tool produces a perfect translation.  The context of the wording may be lost when translated and some translations may lose the intended meaning. Therefore, the San Benito County Health and Human Services Agency cannot guarantee the accuracy of the translated content. 
If any  questions arise concerning the translated version of the website, please refer to the original English version.
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