Requested Event Date:
Start Date:
End Date:
Information
Requestor Contact Information
Name:
Office phone:
Cell:
Email:
Others:
Event Site Address
Site Name:
Street Address:
City:
County:
Zip code:
Event Site Contact Information
Name:
Office phone:
Cell:
Email:
Others:
Vaccination and Testing Site Details
How many days would you like the event to last?
Have you contacted your local health department?
Yes
No
What type of vaccine would you prefer for your site?
Pfizer
Moderna
If Pfizer/Moderna, are you willing to host a second event 21 or 28 days later?
Yes
No
What is your preferred hours of operations for the site requested?
Start Time
End Time
Vaccine Event Requirements
Would you prefer the event to take place inside or outside?
Inside
Outside
How many power outlets are available?
Are restrooms available for staff to access/use during operational period?
Will you need interpreters for this event?
Yes
No
Does your vaccine event need considerations for any minors who may attend without guardian present?
Yes
No
Space Requirements
How large is the requested sites parking lot?
How many exit/entrances on site? (For separate exit/entrance event flow)
How many people can the building accommodate?
If an inside event, how many sq ft can the building allocate?
How many rooms/areas can be dedicated to an indoor event?
Additional Site Information:
Refresh
Please enter text as shown above:
