50 S Main, West Hartford, CT, 06107, US
The purpose of this form is to provide a venue for residents, caregivers, or families to request assistance with obtaining vaccination when there is a mobility issue preventing vaccination through other means. This form is designed for unusual/exceptional circumstances where no reasonable alternatives exist for an at-risk West Hartford resident to obtain a vaccine. Consideration for mobile vaccination applies only to those Town residents who meet the State of Connecticut criteria which is residents over the age of 16. Provided that the criteria for vaccination are met and a need is specified, once the form is submitted, a member of the Health District will follow-up and confirm whether the vaccination can be done away from a clinic.
Form Submission Date/Time
I am filling this form out for:
Is the person who you are requesting assistance for over the age of 16?
Thank you for reaching out to the Town of West Hartford. Currently, the State of Connecticut identifies that the priority for vaccinations is for residents over the age of 16. At this time, we cannot accommodate a mobile vaccination. Please check back for more information or you may contact 860-561-6998.
Name of Person Filling out:
Name of Person requiring mobile vaccine:
Does the person needing a vaccine live in West Hartford?
Unfortunately, the ARCH program is currently limited to West Hartford residents only and this form cannot be used.
Address of Person Requiring Mobile vaccine (MUST be West Hartford resident):
Does the person requiring a vaccine have a mobility issue that prevents them from obtaining a vaccine at a clinic site?
I understand that filling out this form does not guarantee a mobile vaccination, does not schedule an appointment only starts an evaluation process, and that it is only the first step in the screening process. The Health District will carefully evaluate the situation and provide notification of whether a mobile vaccination can be administered. By submitting this form, all of the information is accurate.