Mobile COVID-19 Vaccination or Testing Event Request Form

Mobile COVID-19 Vaccination or Testing Event Request Form

Thank you for your interest in our mobile pop-up specialty COVID-19 vaccination and/or COVID-19 testing services.

Please complete the following e-request form below and a public health professional from the San Bernardino County Department of Public Health will reach out to collect more information and confirm the service for your event e-request.

Completion of this e-request form does not guarantee services will be provided. Thank you for your interest and understanding. We value your partnership.

Organization Information

Organization Type*

Select

Name of Organization*

Street Address*

City/Town/Unincorporated Area*

Select or enter value

Zip Code*

Event Details

County Programs/Departments to be Served*

Type of service requested:*

In order to maintain infection prevention, we are unable to host a mobile vaccination event and mobile testing event simultaneously at a single location.

If you are interested in requesting both services, please submit separate requests with different potential dates.

Select

Potential Date of Event*

Please select a potential date for this event.

Services are not available on Sundays.

Please be aware that this date will remain tentative until a San Bernardino County Department of Public Health representative speaks with the event's point of contact to coordinate and confirm the service.

Contact Information

Point of Contact's Name*

Point of Contact's Email*

Point of Contact's Phone Number*

Phone

Additional Event Information

i.e. population to be served, name of event, other organizations participating at the event, etc.

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