COVID-19 Community Clinic Request

About this service

Public Health - Muskegon County is pleased to offer free-of-charge COVID-19 vaccination clinics for groups at events, businesses, organizations, schools, community centers, places of worship, and more in Muskegon County. We provide the vaccine, supplies, and staff. You provide the date, time, and location. We are also able to provide COVID-19 over-the-counter testing and educational information. Complete this form to request this service.

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* 1. Contact Information

Your Name *

Company or Affiliation

Email Address *

Phone Number *

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* 2. When do you want to host this clinic?

Proposed Date

Date

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* 3. What time frame do you propose for this clinic?

Start Time

Time

AM/PM

End Time

Time

AM/PM

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* 4. What location do you propose for this clinic?

Address *

Address 2

City/Town *

ZIP/Postal Code *

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* 5. Will this be an indoor or outdoor clinic?

Indoor

Outdoor

Unsure at this time

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* 6. Which COVID-19 vaccine are you interested in having at this clinic? (check all that apply)

Pfizer-BioNTech

Pfizer-BioNTech Pediatric (Ages 5-11)

Moderna

Johnson & Johnson (Janssen)

Any of the above

Unsure at this time

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* 7. How many people do you think will participate (get vaccinated)?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. Do you think you will have any children (ages 12 years and up) participate?

Yes

Unknown

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* 9. Are you requesting COVID-19 testing or test kit distribution?

Yes

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* 10. Requests are filled based on schedule availability. This form is not an official commitment. We will contact you to discuss next steps.

I Understand