Vaccine Appointment Eligibility

Please note that pop-up sites can only vaccinate people in eligible tiers. Please see these letters from DDS on eligibility:

High-Risk Medical Eligibility Effective March 15th 
Vendor/DSP Eligibility Letter
Family Caregiver Eligibility Letter

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* 1. Company or Facility Name

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* 2. Site Address

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* 3. Contact Person Name

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* 4. Contact Phone Number

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* 5. Contact Person Email

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* 6. Please indicate if you are able to host a pop-up clinic indoor, outdoor, or both

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* 7. What days of the week is your site available?

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* 8. Please provide additional details on your space if available. (Optional)
i.e. size of parking lot, ability to block off section of parking lot for drive-up, square footage inside, number of entrances/exits in parking lot

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* 9. Approximately how many eligible people associated with your agency (clients, staff, eligible family members of clients/staff) may be interested in coming to your site? 
Please note sign-ups will not be exclusive to you unless you can fill 350 slots.

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* 10. How many volunteers can you provide? (not required)

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