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Programs
Immunization Outreach
Dental Outreach
Kidney Care
Preventive Screening
Request a Care Van
News & Stories
Calendar
Dallas / Ft. Worth Events
Houston Events
Giving
About Us
Staff
Contact
General Inquiries
Sponsorship
Request a Care Van
GIVE NOW
Programs
Immunization Outreach
Dental Outreach
Kidney Care
Preventive Screening
Request a Care Van
News & Stories
Calendar
Dallas / Ft. Worth Events
Houston Events
Giving
About Us
Staff
Contact
General Inquiries
Sponsorship
Request a Care Van
GIVE NOW
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Test Form Page
Vanessa Sanchez
2021-04-23T21:58:52-05:00
Organization
*
Primary Phone Number
*
Facility Name
*
Address 1
*
Address 2
City
*
State
*
ZIp Code
*
Primary Contact Name
*
Primary Contact Email Address
*
Confirmation will come to this email
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?
*
Select a location
School / district facility
Community or non-profit organization building
Place of worship
Other
Preferred Event Date
*
Alternative Event Date
*
Start Time
*
End Time
*
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 Clinic
Other
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 Medicaid
No health insurance
Health insurance that does not fully cover vaccines (underinsured)
American Indian or Alaskan Native
None 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?
*
Select an Option
Anyone who comes in needing immunizations
A 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?
*
Select an Option
Yes
No
What other services, if any, will be offered at the event?
*
Have you asked any other immunization provider(s) to participate in the event?
*
Select an Option
Yes
No
If so, who?
*
How will your event be publicized?
Check all that apply
Email Blast(s)
Radio
Bulletin
Letters to Parents
Posters
Other
Send Request
Thank you for your request. It has been sent.
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