COVID Vaccine Registration Form
The Office of Early Childhood (OEC) and Children’s Hospital Colorado are partnering to help you access a COVID-19 vaccine.

This form is only for child care providers and associated child care staff that work in child care facilities. Every staff member who wants the vaccine needs to submit this form separately.

Due to limited availability, COVID vaccines will only be distributed on a first-come, first-serve basis to those who sign up using this form. You will receive an email from Children's Hospital within 3-5 days of submitting this form with instructions to register for an appointment online.  Please watch your email to ensure you are able to sign up for an appointment. Appointments will begin on or around March 5th.

You must be 18 years of age or older to get the COVID vaccine.

If you have already gotten the first dose of the COVID vaccine, don't submit this form. Please remain with your previous vaccine provider to get your second dose.

If you already have an appointment to get the first dose of the COVID vaccine through another provider don't submit this form.  Please keep that appointment.

If you have any questions, comments or concerns, please contact the Office of Early Childhood at 1-800-799-5876 or cdhs_oec_communications@state.co.us.

The information provided here is how you will be contacted to schedule a vaccine appointment, so please ensure your contact information is correct.
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Email *
Child Care License/Provider ID # *
First Name *
Last Name *
Date of Birth (MM/DD/YYYY) *
You must be 18 years of age or older to get the COVID vaccine. Please make sure you enter a VALID birthdate. Children's Hospital cannot create a record in their system for you to be vaccinated without a valid birthdate. If the birthdate is not valid, you will NOT get any follow-up communication regarding the COVID vaccination.
MM
/
DD
/
YYYY
Job Title *
Please select one.
Child Care License Type *
Cell Phone Number *
Please enter your phone number without dashes or periods.
What county do you live in? *
Enter your Zip Code. *
What Children's Hospital location are you willing to travel to? *
You can select one or both. You will get to choose which location you schedule your appointment at.
Required
I understand that submitting this form means I have NOT gotten any dose of the COVID vaccine from another healthcare provider. *
If you have already gotten the first dose of the vaccine, please remain with your previous vaccine provider to get your second dose.
I understand that submitting this form means that I do NOT have an appointment to get the COVID vaccine with any other healthcare provider. *
If you already have an appointment to get the COVID vaccine through another provider, please keep that appointment.
I understand that the Pfizer and Moderna vaccine require two doses, one month apart, to be most effective. If I get the 1st dose through Children's Hospital, I am committed to also getting the 2nd dose through Children's Hospital. *
If you answer NO to this question, your information will not be sent to Children's Hospital.
I understand that submitting this form only demonstrates that I am interested in this opportunity to get the COVID vaccine through Children's Hospital. I understand that this form does not guarantee Children's Hospital will have the COVID vaccine available for me. *
A copy of your responses will be emailed to the address you provided.
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