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2. First Name*
3. Last Name*
5. Organization Name*
6. Phone Number*
8. Type of Organization*
9. Email*
11. Event Location*
12. Date*
    Date

    Date
14. Brief description of event.
16. What type of event are you interested in?*

    1. COVID-19 Testing
    2. COVID-19 Vaccine 
18. What items will be available for CHA use?*

    1. Table and chairs
    2. Covered area or tent (outdoor only)
    3. Water and refreshments
    4. Free parking for staff

    Check all that apply.

19. Type of event*

    1. Indoor
    2. Outdoor
    3. Drive-thru
    4. Scheduled appointments
    5. Walk-ins
    6. Scheduled appointments and walk-ins

    Check all that apply.

21. Will there be support staff on site from your organization to assist with the clinic?*

    1. Yes
    2. No
23. Would your organization like to host the follow-up (2nd dose) vaccine clinic?*

    1. Yes
    2. No
25. Does your organization plan to handle marketing and promotion of the vaccine clinic?*

    1. Yes
    2. No
27. If yes, how will your organization be handling promotion and marketing of the event?
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field