Vaccine Clinic Request

Please fill out this form if you are interested in bringing vaccines out to your agency, event or community. A DHS Housing for Health representative will reach out to speak more about the opportunities once the form is completed.

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* 1. Name of Requester

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* 2. Contact Email & Phone for Requester

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* 3. Site of Interest

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* 4. Service Planning Area (if known)

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* 5. What are your days/hours of service?

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* 6. How many individuals do you see during your services?

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* 7. What percentage of individuals that you serve are people experiencing homelessness?

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* 8. Are there direct service staff interested in being vaccinated? If so, how many?