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 Select
Barrow
Clarke/Athens-Clarke
Elbert
Greene
Jackson
Madison
Morgan
Oconee
Oglethorpe
Walton
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.
Format: (000) 000-0000.
Contact Email
*
example@example.com
Preferred Date
*
-
Month
-
Day
Year
Date
Preferred START Time
*
Hour Minutes
AM
PM
AM/PM Option
Preferred END Time
*
Hour Minutes
AM
PM
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?
Submit
Should be Empty: