COVID-19 Vaccination Clinical Volunteer Form

Contact Name*
Credentials (MD, RN, LPN, MA)*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Best way to contact you?*
Which hospital is closest to you?
Have you received a COVID-19 Vaccine?
Are you willing to travel with our Mobile Health Unit?
Are you willing to also conduct non-clinical tasks?
Acknowledgement*
I have read the COVID-19 vaccination volunteer information. I understand the eligibility and requirements that are in place.
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Comments
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