Test Form Page - Caring Foundation of Texas

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? *

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

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 *

Who is this clinic intended to serve; what audience will be receiving immunizations? *

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

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?

Email Blast(s)

Radio

Bulletin

Letters to Parents

Posters

Other