Northeast Health District COVID Vaccine Outreach Event Request

Northeast Health District COVID Vaccine Outreach Event Request

For requesting a COVID vaccine outreach event in Barrow, Clarke, Elbert, Greene, Jackson, Madison, Morgan, Oconee, Oglethorpe or Walton counties in Northeast Georgia.
Organization or Employer
Name of Event (if applicable)
Type of Event

Employee Vaccination Event Local Community Event Other Public Event Other
Address of the EVENT *

Street Address

Street Address Line 2

City State

Zip Code
COUNTY of Event: *
Please note that events are limited to our 10-county service area in Northeast Georgia.
Will this event be INDOORS or OUTDOORS? *

Indoors Outdoors
Contact Name *

First Name Last Name
Contact Phone Number *
Please enter a valid phone number.
Contact Email *
example@example.com
Preferred Date *

Month Day Year
Date
Preferred START Time *

Hour Minutes

AM/PM Option
Preferred END Time *

Hour Minutes

AM/PM Option
About how many people do you expect to attend? *
Please enter a number only - this can be an estimate.
In addition to initial doses of COVID vaccines, do you need either of the following?

Booster doses Pediatric (5-11 years old) doses
Please note: Anyone under 18 must be accompanied by a parent/guardian
Will this be a PRIVATE event or open to the PUBLIC? *

Private Event Open to the Public
If event is open to the public and you would like assistance promoting the event, please check the types of promotion you would be interested in:

Fliers Social media posts Newspaper advertising Radio advertising Other
Will health department staff have access to restrooms? *

YES NO
Any additional information or comments that we need to know?
Should be Empty:

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