MOBILE COVID-19 VACCINATION REQUEST FORM

Mobile unit requests for Lynchburg City and Amherst, Appomattox, Bedford and Campbell Counties.

Our community has a variety of free, mobile options available for COVID-19 vaccine distribution. Completing this form will help us determine the best option for your request. You will receive a response to your request within 5 business days. Thank you for your desire to help increase vaccination rates in our community.

Question Title

* 1. Event Location Name

Question Title

* 2. Location Type (i.e. school, LTCF, private business, government facility, etc.)

Question Title

* 3. Address of event

Question Title

* 4. Date for mobile vaccination event

Date / Time

Date

Question Title

* 5. Time range requested (i.e. 9am-noon, 1pm-6pm)

Question Title

* 6. Please provide a description of the vaccination event you would like to have including target audience, type of event, location description, etc.

Question Title

* 7. Is there a specific brand (Pfizer, Moderna, J&J) and/or type (1st dose, booster, 5-11, etc.) that you would like to target? If yes, please describe.

Question Title

* 8. Estimated number of doses, to include walk-in and/or by appointment

Question Title

* 9. Contact information-please provide name, phone and email address