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

 
 
 
 
 
 

Event Details

 

 

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.

 

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.

 
mm/dd/yyyy
 

Contact Information

 

 
 
 
Phone
 

 

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