Please complete this brief expression of interest form to be considered as a host site for CCIC's AmeriCorps program. Upon submission, a CCIC staff member will follow-up with you via email within one week. If you experience any issues or have any questions, please don't hesitate to contact Katie Waters at katherine.waters@childrenscolorado.org.

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* 1. Please complete the contact information below.

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* 2. What county/counties does your organization serve?

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* 3. What type(s) of service(s) does your organization provide to the community?

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* 4. What is the staff size of your organization?

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* 5. Have you met with a CCIC staff person regarding the AmeriCorps program and/or watched the informational webinar?

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* 6. Please describe how your organization currently works or is interested in future efforts to support and improve immunization efforts in your community.

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* 7. Please indicate which activity(ies) you think an AmeriCorps member could support in your community using the options below.  If you have additional ideas or want to provide further detail, please use the comment box below.

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* 8. How did you hear about CCIC's AmeriCorps program?

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