Volunteer Request Form
This is to capture contact information for people who are willing to volunteer for clinics
Volunteer Name
First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you currently vaccinated against Covid-19?
First dose Completed Both Dose complete Not Vaccinated Yet
Are 65 or older?
Yes No
Are you a medical practitioner who can perform immunizations?
Yes No
If yes, do you carry your own liability insurance?
Yes No
How would you like to help? (check all that apply
On clinic days, helping with patient intake, screening, and related tasks On clinic days, as a professional (drawing and/or administering doses) On clinic days, as someone with some emergency response training (CPR/First Aid) to monitor patients after their immunization Before and after clinics, "adopting seniors" to schedule them, complete all necessary registration, plus remind them of appointments for second doses.
What is your general availablity?
Mornings Afternoons Evenings Not Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How many days each week would you be willing you help us, at most?
Should be Empty:

Volunteer Request Form