Primary Phone Number
Primary Contact Email Address
Secondary Contact Name
Secondary Email Address
On-Site Contact Name
On-Site Email Address
On-Site Phone Number
Brief Event Description
Preferred Event Date
Alternative Event Date
If 'other', please describe your desired clinic and type of location
If requesting a Student Immunization Clinic, please select the TVFC criteria that apply to any of the students who will attend
All children must be 18 years of age or younger
Enrolled in MedicaidNo health insuranceHealth insurance that does not fully cover vaccines (underinsured)American Indian or Alaskan NativeNone of these apply
Estimated Number of Children Receiving Immunizations
Estimated Number of Adults Receiving ImmunizationsOnly if a community clinic
Will the event be open to the public or a private event?
If private, what is the criteria of who is attending?
Has your school district/organization partnered with The Care Van program before
What other services, if any, will be offered at the event?
Have you asked any other immunization provider(s) to participate in the event?
If so, who?
How will your event be publicized?Check all that apply
Email Blast(s)RadioBulletinLetters to ParentsPostersOther