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Westland COVID-19 Vaccination Registration Form

  1. Vaccinate Westland 2=logo
  2. This form is for registering with the City of Westland for a COVID-19 vaccination. This program is available for residents of Westland that meet the current Wayne County eligibility criteria.
  3. All information provided in this form is subject to Freedom of Information Act requests subject to State law.
  4. Are you a resident of Westland?*
  5. Will You Need Mobility Assistance (a wheelchair)?
  6. Once the City receives this form, you will be added to the list of people interested in receiving a COVID-19 vaccination. As vaccination events become available we will contact you to schedule an appointment time for the date of the event.
  7. Once you have been added to the registration list, your name will remain until we can schedule an appointment for you. You do not need to register more than once. As doses are limited we strongly suggest to continue working with your health provider and other agencies to try to get vaccinated while waiting to be vaccinated through this program. If you are not 65+ years old, we will contact you once vaccinations are made available for your age group.
  8. On the day of your appointment make sure to arrive on time with a government issued photo identification card. Your medical insurance information/card is also requested if available.
  9. For more information please visit the Westland Coronavirus Hub Westland COVID-19 Hub or contact the Mayor's Office at 734-467-3200.
  10. Leave This Blank:

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