DeKalb Public Health Mobile Flu Vaccination Clinic Request Form

DeKalb County Board of Health
Mobile Flu Vaccination Clinic Request Form

Thank you for your interest in helping get people vaccinated. Please complete this form if you are interested in hosting a mobile flu vaccination clinic at your organization. Host organizations must be in DeKalb County, Georgia, and include places of worship, nonprofits, businesses, schools, and community organizations. Completing this form is the first step to notify us of your interest, but it does not guarantee that we will fulfill your request.

If you need help with this form, please email don.brundage@dph.ga.gov
or alina.matthew@dph.ga.gov.

*=questions that are required

Requesting For*

Flu Vaccine Clinic Location*

Organization Name*

Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Number of Participants*

Preferred Day*

Preferred Time*

Contact Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

Please schedule this group for a mobile flu vaccine clinicPlease have a representative contact us about a mobile flu vaccine clinic

Once submitted, please print out one of the forms on the following page, fill it out and bring it with you during your mobile flu vaccine clinic appointment.

Enter the message as it's shown*