Regional Care Van Request Container 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? 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 × Vanessa Sanchez2019-11-18T16:26:52-06:00November 18th, 2019| Share this page! FacebookTwitterRedditLinkedInPinterestEmail