Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

MiCo COVID-19 Vaccination Interest Form for Childcare Providers

  1. Miami County COVID-19 Vaccination Interest Form for Childcare Providers

    The following form is for LICENSED CHILDCARE PROVIDERS ONLY who are interested in receiving the COVID-19 vaccination for themselves and/or staff. The Miami County Health Department is following vaccine recommendations from the Centers for Disease Control and Prevention and the Kansas Department of Health and Environment.

  2. By completing this form, you as a childcare provider in Miami County, are indicating you would like to be contacted by Miami County Health Department if COVID-19 vaccine becomes available. This does not guarantee you will receive the vaccine from Miami County Health Department, nor does it secure an appointment at this time. If you are able to obtain the vaccine, or need to request an addendum to the number of requested vaccine, contact us so you can be removed from this list, or so we can make an addendum. If you are not a licensed childcare provider in Miami County, KS please do not fill out this form.

  3. Are you willing to be placed on a "stand-by" list if extra vaccinations are available at the end of the day?*

    The stand-by list means you will likely be called with short notice to come in for a vaccination.

  4. Questions? Please contact Miami County Health Department by email at: cbeer@miamicountyks.org

  5. Leave This Blank:

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