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Fairbanks Area Mobile/Onsite COVID-19 Vaccine Clinic Request

Sleeves up for Summer: Let's get Alaska up and running
Thank you for your interest in hosting a COVID-19 vaccine clinic!

Requirements to host a clinic include:
  • The host must provide at least one employee or responsible person willing to assist and be present for the duration of the event.
  • The host must have commitments from a minimum of 10 people who wish to be vaccinated.
Please use this form to request a Fairbanks area vaccination clinic. If you have questions, please contact Fairbanks Public Health Center at 907-452-1776.
1.What is the name of your organization?(Required.)
2.Description of the event you are hosting(Required.)
3.Point of contact name
(Required.)
4.Point of contact email(Required.)
5.Point of contact phone number(s)
(Required.)
6.What is your estimate of the minimum and maximum number of doses needed?(Required.)
7.Please list date, start and end time of the event? Are you requesting a one-time or recurring event?(Required.)
8.What is the physical address where you plan to host the vaccination clinic?(Required.)
9.City and Zip/Postal Code(Required.)
10.Please describe the space that would be available for a vaccination clinic. Is this a large community room, multiple rooms, is parking available, etc.? Please include approximate square footage. Will tables and chairs, WiFi or cell service be available?(Required.)
11.How many staff members or volunteers will be available to assist? This might include assistance with traffic flow, communications, form completion, timekeeping, etc. (no medical training required.)(Required.)
12.Are there any other considerations about the space or population being served that you would like us to know?(Required.)