Offsite Vaccination Clinic Request Form

Please note:

We cannot guarantee our ability to fulfill your clinic request, but we will do our best. Please give us as much notice as possible to make for a successful clinic!

Name:

First NameLast Name

Organization:

Name of the Organization

Job Title:

Position with the Organization

Phone Number:

Please include area code.Format: (000) 000-0000.

Email:

example@example.com

Vaccines Offered:

Setting:

Desired date:

Specific date or availability (if flexible)

Event Name:

Date:

MonthDayYear

Location:

Type:

Estimated number of people wanting vaccinations:

Number

Target population:

Employees, middle school students, parents, etc.

Target age group:

Would you like any digital advertisement materials?

Desired materials:

Flyers, Social Media Posts, etc.

Would you like us to advertise this clinic to the public?

Other information:

Offsite Vaccination Clinic Request Form

Contact Information:

Clinic Information: