Business COVID-19 Vaccine Interest
Street Address Line 2
State / Province
Postal / Zip Code
Business Point of Contact:
Business Point of Contact Email:
Business Point of Contact Phone Number:
Please enter a valid phone number.
Approximate number of employees interested in COVID-19 vaccine:
Approximate number of family members of employees interested in COVID-19 vaccine (SCHD has had many inquiries regarding this) :
Preferred day of the week (check all that apply):
Preferred time of the day (check all that apply):
AM (ex. 9:00AM-12:00PM)
PM (ex. 1:00PM-5:00PM)
Where does your facility have space to host a vaccine clinic?
If your facility does not have many employees interested, would your employees be interested in a centralized location within walking distance of your facility?
Additional comments for SCHD:
Should be Empty: