COVID-19 Vaccine Event Interest Form

PLEASE READ: If you would like to schedule an appointment for the COVID-19 vaccine please call 313-230-0505. This form is for businesses only. Thank you for your interest in partnering with the Detroit Health Department (DHD) to protect the health and well-being of our community. DHD offers various options for events or resources related to the COVID-19 vaccine. This includes providing educational resources and/or hosting a COVID-19 vaccination clinic at your organization. Please complete this interest form and a Detroit Health Department representative will follow up with you in 24-48 business hours.

Which of the following categories best applies to your organization?*
Which service(s) are you requesting from the Detroit Health Department?*
Which type of education would you like?*

A vaccination clinic date will be confirmed once you speak with a Detroit Health Department representative.

Please write the street number only. E.g. If your address is 100 Mack, you will input "100" here.

Please write the street name only. E.g. If your address is 100 Mack, you will input "Mack" here.

Mobile phone numbers are preferred. (ex. format: 555-555-555)

If the point of contact does not have an email address, please input "N/A"

Select
Caret IconCaret symbol

If you are unsure, please write "Unknown".

Powered by Smartsheet Modern Logo On Light
Privacy Notice|Report Abuse