Flu Clinic Host Interest Form
Contact First and Last Name
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Contact email
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Best number to contact you:
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Organization or Group Name (If applicable)
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Organization or Group Type
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Please list your organization/group type (business, government, nonprofit, healthcare, school, workforce contractor/employee, etc).
Organization Address (If applicable)
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Organization Zip code
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What languages does the community speak?
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Please list the main languages spoken in your area.
Is there a large open space available for set up?
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Example: parking lot, large driveway, etc.
Do you have access to electricity for admin staff?
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Will you be able to provide at least 5-6 tables?
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(for admin staff, registration, vaccination, etc)
Will you be able to provide at least 12-13 chairs for admin staff?
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Preferred Dates/Times
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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?
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Please put ideal dates and times below if known:
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