Texas Care Van Request Form

Organization

Primary Phone Number

Facility Name

Address 1

Address 2

City

State

Zip Code

Primary Contact Name *

Primary Contact Email Address *

Secondary Contact Name

Secondary Email Address

On-Site Contact Name

On-Site Email Address

On-Site Phone Number

Event Name

Brief Event Description

Where will this clinic be held?
—Please choose an option—School / district facilityCommunity or non-profit organization buildingPlace of worshipOther

Preferred Event Date

Alternative Event Date

Start Time
—Please choose an option—7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm

End Time
—Please choose an option—8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm9pm

What kind of clinic(s) are you requesting?
All Children Immunization Clinic (held Jul-Sep and Jan-Feb only)Children Flu Vaccine Only (held Oct-Feb)7th Grade Prep Immunization Clinic (MCV4, Varicella and HPV for children entering 7th grade)High School Senior Clinic (MCV4 and Men B for graduating seniors)Adult Flu Vaccine ClinicOther

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 Immunizations
Only if a community clinic

Who is this clinic intended to serve; what audience will be receiving immunizations?
—Please choose an option—Anyone who comes in needing immunizationsA specific/limited group of people

If a specific/limited group, who will be allowed to get immunizations?

Is your organization able to provide any medical professionals who can screen immunization records? If so, how many?

Has your school district/organization partnered with The Care Van program before
—Please choose an option—YesNo

What other services, if any, will be offered at the event?

Have you asked any other immunization provider(s) to participate in the event?
—Please choose an option—YesNo

If so, who?
How will your event be publicized?
Check all that apply
Email Blast(s)RadioBulletinLetters to ParentsPostersOther