Arkansas Heart HospitalCOVID-19 Vaccination Notification List COVID-19 Vaccination Notification List Fill out the form below to notified when time-slots may become available for you. (By filling out this form we will contact you only in regards to your vaccination eligibility and not for marketing purposes.) Name* First Last Date of Birth* Month Day Year Phone*Email* Eligibility Group*Based on the ADH guidelines which eligibility group are you in?Please ChoosePhase 1-APhase 1-BPhase 1-CNoneHiddenQualifying Criteria*Select the criteria that qualifies you to receive the vaccine either now or in a future phase. Please ChooseAge 65 or OlderEducation Worker (K-12, Child Care, Higher Ed)Healthcare Worker or First ResponderFrontline Essential Worker in Postal, Police, Groceries, etc.People with intellectual or developmental disabilitiesSevere COVID-19 Associated Illnesses or ConditionEssential Worker in Transportation, Food, Energy, Water, etc.None of the aboveHiddenSelect the Education Type* K-12 Higher Ed Child Care HiddenPlease select illness or condition Cancer Chronic Kidney Disease COPD Heart Conditions Weakend Immune System Obesity Sickle Cell Disease Type 2 Diabetes Pregnant HiddenPlease select your industry Police, fire, other first responders not in 1-A Corrections Worker Food and Agriculture Worker Essential Government Worker Grocery Store/Meal Delivery Postal/Package Delivery Service Worker Public Transit Worker Houses of Worship Worker Manufacturing Worker HiddenPlease select your industry Transportation and Logistics Water and Wastewater Food Service Shelter and Housing Energy Media Public Health Public Safety You Currently QualifyPlease submit the form to be placed on a list so we can notified you when more time-slots become available. You Do Not Currently QualifyIt looks like you do not currently qualify for the COVID-19 vaccination based on the ADH Vaccination Plan. Please submit the form so we can let you know when you may become eligible based on any new guidelines that are released.CAPTCHA Δ