Flu Clinic Host Interest Form

 
 
 
 
 
Please list your organization/group type (business, government, nonprofit, healthcare, school, workforce contractor/employee, etc).
 
 
 
Please list the main languages spoken in your area.
 
 
Example: parking lot, large driveway, etc.
 
 
(for admin staff, registration, vaccination, etc)
 
 
Please list your preferred dates, timeframes, and/or times of the day for the event.