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
1
2
3
4
Tuesday
5
6
7
8
Wednesday
9
10
11
12
Thursday
13
14
15
16
Friday
17
18
19
20
Saturday
21
22
23
24
How many days each week would you be willing you help us, at most?
Please Select
1
2
3
4
5
6
7
Submit
Should be Empty: