Champions for HealthImmunization Clinic Interest Form

Champions for Health

Immunization Clinic Interest Form

Events are funded by and held on behalf of

the County of San Diego Health & Human Services Agency

Contact Name

Contact's Email

Contact's Number

May we text you at this number if needed?

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Organization Information

Name of organization making request

Organization's street address

City

Zip Code

What type of organization are you?

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If other, please explain

Will the clinic happen at the listed address?

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If no, what is the clinic event address?

Event Site Details

Will the site be able to provide 5-6 chairs?

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Will the site be able to provide 10-12 chairs?

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Will the event be an inside or outside location?

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If outside, will the side provide 4-5 canopies?

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Will the site have access to restrooms for staff?

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Will the site have access to electricity?

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Will there be access to wifi?

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Additional questions

Who would be the target audience for this event?

What are the language needs for your community?

Would this be a one time event or a series?

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Would you like a free health presentation during your clinic?

With our Live Well Speaker's Bureau program, we offer the opportunity to incorporate an informative health presentation into your event, whether it's before, during, or after the clinic. These presentations cover a wide range of health topics and serve as an excellent enhancement to your gathering

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By clicking submit, you are agreeing that your organization will complete the following if an event is confirmed:

Promote the event through all available channels (email, text bank, social media, etc.)
Communicate any event changes to Champions for Health in a timely manner
Confirm a point of contact that will be available the day of and through the entirety of the clinic

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