Atlantic County Regional
COVID 19 Vaccination Center
 Vaccine Recipient Registration

Please complete following information below.

First Name:  
Last Name:  
Birthdate:  
 
 
* You must be at least 5 years of age to receive the Pfizer vaccine, at least 18 years of age to receive Moderna and at least 18 years of age to receive Janssen (J&J) vaccine

* Minors are required to be accompanied by a parent or guardian
Phone Number:  
Home Address 1:  
Home Address 2: City:  
State:  
Zip:  
Create an Account
UserName:

Verify UserName:

Email:
(email will be used to receive reciepts and other notifications)
Verify Email:

Alternative Email:
(email will be used as an alternative to receive reciepts and other notifications)
Verify Email:

Password:
Confirm Password:

Notifications and Alerts

We may contact you via telephone, text, or e-mail to remind you of upcoming appointments, receipt of services, and general information on AtlantiCare programs and services.


If you do not wish to receive email communications for the following, please uncheck the box

 Vaccination Communications

  AtlantiCare Programs and Services Communications

If you do not wish to receive text message communications for the following, please uncheck the box.

 Vaccination Communications

  AtlantiCare Programs and Services Communications