COVID-19 Vaccine Clinic Request

Community Name*
Community Address*
Street Address Address Line 2 City State ZIP Code
Primary Community Contact Name*
Primary Community Contact Phone Number*
Primary Community Email Address*
Has your community previously hosted a COVID-19 vaccine clinic*
- Yes
- No
Date of last COVID-19 vaccine clinic (if applicable)
Date Format: MM slash DD slash YYYY
Which COVID-19 vaccine was administered (if applicable)?
- Pfizer
- Moderna
- J&J (Janssen)
Approximate number of individuals that need to be vaccinated?
Residents / Clients*
Staff*