Champions for Health COVID-19 POD Volunteer Form

Thank you for your interest in wanting to volunteer at our COVID-19 vaccination PODs. Whether you are looking to help vaccinate or aid at registration, we are honored to have your support! Our COVID-19 vaccination PODs will focus on hard to reach populations such as senior nursing facilities, migrant workers at the farms, the homeless and more. Please complete our form below and you will be notified of the next steps within 72 hours on next steps.

First and Last Name*

Email:*

Best Number to Contact You:*

May We Contact You Via Text At Number Provided?*

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Title:*

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If you picked "Other Licensed Medical Profession" or "Other", please specify below:

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If medical professional, please state the medical license number below. Note all volunteers will be screened prior to approval. You will be notified that you have been cleared to volunteer via email or text.

License Number:*

If planning to vaccinate, have you reviewed County HHSA Moderna/Pfizer Training slides and completed the post-test? If no, we will share slides and post-test links in the follow-up email. If not sure we can check. Note all vaccinators must complete and pass post-test prior to volunteering as a medical volunteer.

Have You Reviewed Slides and Completed Post Test?*

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Are you affiliated with an organization or association? For example, CMA, SDNAHN, Scripps, Etc.

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