Vaccine Clinic Interest Form
Organization Information
Organization / Group Name
*
Contact Person Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your relation to the company?
*
Please Select
Owner
Executive / Leadership
Human Resources (HR)
Office Manager
Operations Manager
Wellness Coordinator
Safety Coordinator
School Administrator
Church Leader / Pastor
Event Coordinator
Employee / Staff Member
Volunteer
Parent / Community Member
Other
Please provide your relation
*
Are you the primary decision maker for this clinic?
*
Yes
No
Who is the primary decision-maker?
Clinic Details
Where would the clinic be held?
*
Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Approximately how many people would participate?
*
20-29
30-49
50-74
75-99
100+
Scheduling Information
Preferred Day(s) of the Week
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Time Window
Morning (9am-11am)
Midday (11am-1pm)
Afternoon (1pm-3pm)
Evening (3pm-5pm)
Other
Vaccine Interest
Which vaccine(s) are you interested in offering?
*
Flu
COVID-19
Shingles
Pneumonia
Tdap
Other
Insurance & Eligibility
What type of insurance will participants be using?
*
Company (most will have the same)
Individual (each may be different)
Cash
Space & Setup
Is there space available for vaccinations?
*
Yes
No
Please describe the space available
*
Additional Notes
Anything else we should know?
Submit
Should be Empty: