Volunteer Request Form
This is to capture contact information for people who are willing to volunteer for clinics
Please enter a valid phone number.
Are you currently vaccinated against Covid-19?
First dose Completed
Both Dose complete
Not Vaccinated Yet
Are 65 or older?
Are you a medical practitioner who can perform immunizations?
If yes, do you carry your own liability insurance?
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?
How many days each week would you be willing you help us, at most?
Should be Empty: