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COVID-19 Vaccine Clinic Volunteer Application

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This form has been modified since it was saved. Please review all fields before submitting.

Steps

1. Demographic Information This section is complete This section is incomplete
2. Emergency Contact This section is complete This section is incomplete
3. Additional Questions This section is complete This section is incomplete

Demographic Information

First Name*
Middle Name
Last Name*
Suffix
Preferred Name*
Date of Birth*
Address1
Address2
City
State
Zip
Primary Phone Number*
Secondary Phone Number
E-mail Address
Have you received your COVID-19 Vaccine?*
1. Yes
1. No
If no, would you like to be vaccinated?
1. Yes
2. No
3. Unsure
Continue

Emergency Contact

Emergency Contact First Name*
Emergency Contact Last Name*
Emergency Contact Relationship*
Emergency Contact Primary Phone Number*
Emergency Contact Secondary Number
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Additional Questions

Are you 18 years of age or older?*
1. Yes
2. No
Are you medically fit/eligible to work/volunteer?*
1. Yes
1. No
Are you able to stand for long periods of time?
1. Yes
2. No
Are you able to lift 15-20 pounds?
1. Yes
2. No
Would you be able to work in inclement conditions(hot, cold, rain, etc)?
1. Yes
2. No
Do you hold any healthcare licenses?*
1. Yes
1. No
If yes, Please list license types.
If you hold licenses that would be relevant to volunteering in vaccination clinics, please bring copies with you.
Do you hold any Life Support certifications(CPR, EMT, etc)?*
1. Yes
1. No
If yes, Please list certification types.
If you hold any life support certifications relevant to volunteering at a vaccine clinic, please bring copies with you.

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