COVID-19 - DISASTER RECOVERY MINISTRY

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COVID-19

Host a Vaccination Clinic!

Would your church like to host a COVID-19 vaccination clinic? Complete the request form for assistance in coordinating a vaccination event on your church property. The clinic can be hosted in the parking lot with little disruption to the church.

Please contact Trish Warren, Disaster Response Coordinator, for questions or additional information at pwarren@flumc.org.

* Indicates required field

Who is completing this form? *

First

Last

What is the name of the church requesting the clinic? *

Which district are you in? *

What is the church address? *

Line 1

Line 2

City

State

Zip Code

Country

Who is the point of contact for this event? *

What is the phone number for the point of contact? *

Choose Would you prefer the clinic to be held indoors our outdoors? Please remember, there is a 15 minute observation period so we do recommend an indoor vaccination clinic. *

Indoor Outdoor

Please list the date you'd prefer to hold the clinic. *

Please list a backup date for the clinic. * *

What time would you like the clinic to be? (Clinics are held for 4 hours) *

Are you able to provide 4 tables and 30 chairs? *

Yes No

Do you have WIFI available for the clinic staff? Choose One *

Yes No

Why would you like to host a vaccination clinic (may select multiple)? *

Lack of pharmacies in the area. Lack of transportation in the area. Vaccine hesitancy which has been alleviated. Other

Other Response: *

How will this event be promoted by your church (may select multiple)? The conference will utilize social media and the Disaster Recovery Newsletter. *

Church Bulletin Social Media OptionPromoting through church childcare and/or after school program 3 Door Knocking Signage Other (please respond below)

Other Response: *

Will you be partnering with other agencies to promote this event? *

Yes No

If partnering with other agencies, who will you be partnering with? *

How many vaccines do you anticipate needing? *

Which vaccines would you like (may select multiple)? *

Pfizer - ages 5 and up (requires second dose 21 days after first dose) Moderna - ages 18 and up (requires second dose 28 days after first dose) Johnson & Johnson - ages 18 and up (single dose) Flu vaccine (not guaranteed, but can be requested)

Do you acknowledge that if a minimum of 20 vaccinations is not met at the first-dose event, a second-dose event will not be scheduled? Alternate locations will be provided to attendees. *

Yes No

Comments/questions? *

Submit

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Disaster Recovery is a ministry of The Florida Conference of The United Methodist Church.

450 Martin L King Jr Avenue | Lakeland, FL | 33815

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