COVID-19 Volunteer Vaccinator Sign-Up Sheet

Please visit this website to verify your eligibility to vaccinate: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/Authorized-Licensees.aspx#

Thank you for your interest in assisting with the COVID-19 vaccination clinics in the Yuba and Sutter area. Please take the time to answer this short survey to be added to our list of potential vaccination volunteers. Someone from Public Health will reach out with volunteer opportunities as they arise.

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* 1. Full Name

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* 2. Date of Birth

Date / Time

Date

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* 3. Address

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* 4. Phone Number

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* 5. Email

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* 6. License Number

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* 7. License Board

Medical Board of California

Osteopathic Medical Board of California

Board of Registered Nursing

Physicial Assistant Board

Board of Vocational Nursing and Psychiatric Technicians

Respiratory Care Board of California

Board of Pharmacy

Emergency Medical Services Authority

Dental Board of California

Naturopathic Medicine Committee

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* 8. Days Available to Volunteer

Sundays

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Other (please specify)