Assembly Hall COVID-19 Vaccine Waitlist

By completing this form, you’ll be added to the waitlist for COVID-19 vaccine appointments at Simon Skjodt Assembly Hall.

You do not have to be affiliated with IU or have an IU email address to add yourself to the waitlist.

Email Address (* required)

Confirm Email Address (* required)

Waitlist Timing

This is a short notice COVID-19 vaccine wait list. If you are on the wait list and we have a vaccine dose available last-minute, we will call you from 812-856-1919. We will give you as much time as possible, with a minimum notice of 30 minutes to arrive at the clinic to get vaccinated. If you are unable to make your appointment when contacted, you will forfeit your waitlist and will be required to resubmit this form to be considered for a future appointment.

The clinic is located at Simon Skjodt Assembly Hall, 1001 E 17th St, Bloomington, IN 47408. These appointments will generally be at the end of the normal clinic hours.

These waitlist entries are reset every Saturday at 11:59pm.
Form entries entered beginning Sunday at 12:00am are valid until the next Saturday and will be used for the Simon Skjodt Assembly Hall clinics held during that week ONLY. Prior week entries are not considered after Saturday 11:59pm.
For example: A form entered Sunday, March 28th will be eligible for waitlist doses at the Simon Skjodt Assembly Hall site Sunday, March 28th-Saturday, April 3rd.

Your Information

First Name (* required)

Last Name (* required)

Phone Number (* required)

Can we text this number? (* required)

Date of birth (* required)

Sex (* required)

This question is required by the Indiana Department of Health patient registration in order for them to communicate with your insurance provider.

Male

Female

Non-Binary

Waitlist Information

Do you have an underlying condition that is putting you at increased risk? (* required)

Adults of any age with the conditions specified in the following link: https://www.coronavirus.in.gov/files/Eligibility%201.5.21.pdf

Are you an educator? (* required)

Adults of any age working as an educator as specified in the following link: https://www.coronavirus.in.gov/files/Eligibility%201.5.21.pdf

If selected, we will call you. Would you prefer a text or email invite for registration? (* required)

Text Message

I attest the information on this form is correct, give permission for its storage and am able to arrive at the clinic in specified timeframe if selected. (*required)

Cancel

Your Email Address

Waitlist Timing

The clinic is located at Simon Skjodt Assembly Hall, 1001 E 17th St, Bloomington, IN 47408. These appointments will generally be at the end of the normal clinic hours.

Your Information

Waitlist Information