COVID-19 Vaccination Events

COVID-19 Group Vaccination Request

Please complete the form below to request a group vaccination event for your worksite, church, community organization, or other group. We will call the contact person listed below to discuss possible dates, locations, and registration options.

Primary Contact Person*
First Name Last Name
Group or organization
Phone*
Email
Would this event be open to the public?
- Yes - we want to host a public event with open registration
- No - this event would only be for people we identify, such as our staff or members
- Both - this event would be mostly for people we identify, but it would be okay for others to attend
How many people would receive a COVID-19 vaccine at this event?
Do you have a proposed location in mind?
A vaccine event location would be a public location (no private homes) with room for all participants to be seated 6 feet apart for 15-30 minutes after receiving the vaccine, 1-2 tables for use by nursing and clerical staff, and adequate parking. It would be available on the proposed event date and 3-4 weeks later for second doses (only one date is needed for the J&J vaccine).
- Yes - we have an ideal location available
- Maybe - we have a location in mind that might work
- No - we need help finding a location
Is there anything else you'd like to share?
Comments
This field is for validation purposes and should be left unchanged.

COVID-19 Group Vaccination Request

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