Flu Clinic Host Interest Form
Contact First and Last Name
*
Contact email
*
Best number to contact you:
*
Organization or Group Name (If applicable)
*
Organization or Group Type
*
Please list your organization/group type (business, government, nonprofit, healthcare, school, workforce contractor/employee, etc).
Business
Government
Nonprofit
Healthcare
School
Workforce Contractor/Employee
Medical Association
Community-Based Organization
Medical Volunteer Organization
Not Applicable
Other
Organization Address (If applicable)
*
Organization Zip code
*
What languages does the community speak?
*
Please list the main languages spoken in your area.
Is there a large open space available for set up?
*
Example: parking lot, large driveway, etc.
Yes
No
I'm not sure
Would need more details first
Do you have access to electricity for admin staff?
*
Yes
No
I'm not sure
Will you be able to provide at least 5-6 tables?
*
(for admin staff, registration, vaccination, etc)
Yes
No
I'm not sure
Will you be able to provide at least 12-13 chairs for admin staff?
*
Yes
No
I'm not sure
Preferred Dates/Times
*
Please list your preferred dates, timeframes, and/or times of the day for the event.
Would you be ok to open this event to the community?
*
Yes
No
Please put ideal dates and times below if known:
Send me a copy of my responses
Email address
Powered by
Smartsheet Forms
Privacy Policy
|
Report Abuse
Your submission is being processed. Please do not close this browser window until complete.