Sac Collab Vaccine Ambassador Support Request Form

Thank you for your interest in our Sac Collab Vaccine Ambassador Program outreach and activities support. Please complete the request form and a representative from the Sac Collab Vaccine Ambassador Program will reach out.
*Completion of this form does not guarantee or confirm the services requested.

Question Title

* 1. Please indicate today's date.

Date:

Date

Organization Information

Question Title

* 2. Please provide your organization and contact information.

Your First Name, Last Name

Name of Organization

Email Address

Phone Number

Event Details

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* 3. Please provide the event details and contact information.

Contact Person for Event/Activity (First Name, Last Name)

Email Address

Phone Number

Date of Event/Activity

Start and End Time of Event/Activity

Event/Activity Address

Zip Code

Question Title

* 4. Please indicate the type of event/activity:

Question Title

* 5. What is the approximate number of people attending or to be reached?

0-50

51-100

101-200

200+

Question Title

* 6. What are you requesting?

Vaccine Ambassador to Table (#of Ambassadors will depend on event size)

Canvassing Prior to Event/Activity

Phone Banking Prior to Event/Activity

Phone Banking During the Event/Activity

Social Media Push

Education Forum Participation or Presentation Support

Handout Materials (e.g., information about vaccines, vaccine myths & facts, children & the vaccine, general information)

Additional Requests (please specify):

Question Title

* 7. Please indicate any translation support service needs for the event/activity:

Question Title

* 8. Additional event/activity information?

Please make sure you answer all questions as completely and accurately as possible. A Sac Collab Vaccine Ambassador Program representative will reach out within a 24-48 hour time frame of the submission date, Monday through Friday. If the request form is submitted on a Friday, a follow-up may not occur until Monday. If you have any immediate questions regarding your request, please email Laura Jackson at ljackson@sierrahealth.org.