COVID-19 Vaccination Response Team Recruitment Form

COVID-19 Vaccination Response Team Recruitment Form
Thank you for your interest in taking part in the COVID-19 Vaccination Response Team. Interested persons must have the necessary license for the practice of their profession during the period of vaccination efforts.
Please fill out the information below and upload the necessary documents in the upload field provided. We recommend that the files to be uploaded to be either in image format or PDF.
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
MonthDayYear
Date
Gender
MaleFemale
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
I am a:
StudentProfessional
Position/Title
Affiliation/Organization
Highest Educational Attainment
Course
Are you currently studying?
YesNo
Course currently taking

Please select your available slots

Please check the roles you are interested in
ClericalImmunizerClinical SupportOther
Please upload the following:
Driver's License
Cancelof
CPR Training Certification
Cancelof
HIPAA Training Certification
Cancelof
Certification in vaccination-related courses
Cancelof
FWA Certification
Cancelof
COVID-19 Management Training
Cancelof
PA State License
Cancelof
Other relevant certifications
This is a multiple-upload field. Upload as many documents as needed
Cancelof
Employment Capacity
Are you qualified to work in the United States?
YesNo
Have you been convicted of any felony in or outside the United States?
YesNo
Comments
Character References
Should be Empty:

Please upload the following: