Wufoo

Flu Shot Clinic Request Form

To request a flu clinic at your worksite, church, or community center, please complete the folowing information.

Organization's Name *
Contact *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * - (###) - ### ####
Email
Day Preference(s)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Time Preference(s)
Morning Afternoon Other
Number of Employees at Site
Number of Work Sites
Would you like your site to be open to the public and advertised in our event mailer?
Yes No
Do Not Fill This Out