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COVID-19 Vaccine Clinic Request Form

  1. What items will be available for CHA use?*

    Check all that apply.

  2. Type of event*

    Check all that apply.

  3. Will there be support staff on site from your organization to assist with the clinic?*
  4. Would your organization like to host the follow-up (2nd dose) vaccine clinic?*
  5. Does your organization plan to handle marketing and promotion of the vaccine clinic?*
  6. Leave This Blank:

  7. This field is not part of the form submission.