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).

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.

Do you have access to electricity for admin staff?*

Will you be able to provide at least 5-6 tables?*
(for admin staff, registration, vaccination, etc)

Will you be able to provide at least 12-13 chairs for admin staff?*

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?*

Please put ideal dates and times below if known:

Send me a copy of my responses

Email address