COVID Vaccine Clinic Request Form
Please complete this form to request an onsite COVID vaccine clinic. Requests will be prioritized based on our staffing availability and vaccine supply.
Business or organization requesting the clinic:
Please provide a brief description of the business or organization (ex.: what you do and who you serve):
Contact phone number:
Please enter a valid phone number.
Address where the clinic would take place:
Street Address Line 2
State / Province
Postal / Zip Code
Is the facility to be used for the clinic indoors or outdoors?
Could be either, based on need
Who would or could be vaccinated at the clinic?
Business or organization staff
Patrons, patients, clients, etc
Youth ages 12-17
If the general public can attend the clinic, would your business or organization be willing to promote the clinic on your website and/or social media channels?
Please estimate how many individuals might be vaccinated at this clinic:
Scheduling the clinic will depend on our staffing and vaccine supply but we'd love to know when would work best for you for our planning. Please share what dates/times would be ideal for this clinic to take place.
The vaccine we can offer will depend on our supply and scheduling logistics (for Pfizer or Moderna related to 2nd doses). Which vaccine would you prefer to have available at this clinic? Please select all that apply.
Pfizer (2 doses 21 days apart, available for those 12+)
Moderna (2 doses 28 days apart, available for those 18+)
Johnson & Johnson (1-dose, available for those 18+)
If Moderna or Pfizer are offered during the clinic, will you be able to host us for a 2nd dose clinic at the appropriate time (21 days later for Pfizer or 28 days later for Moderna)?
Is there anything else we should know related to your request?
Should be Empty: