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Sleeves up for Summer: Let's get Alaska up and running
Thank you for your interest in hosting a COVID-19 vaccine clinic!

Requirements to host a clinic include:
  • The host must provide at least one employee or responsible person willing to assist and be present for the duration of the event.
  • The host must have commitments from a minimum of 10 people who wish to be vaccinated.
Please use this form to request a Fairbanks area vaccination clinic. If you have questions, please contact Fairbanks Public Health Center at 907-452-1776.

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* 1. What is the name of your organization?

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* 2. Description of the event you are hosting

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* 3. Point of contact name

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* 4. Point of contact email

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* 5. Point of contact phone number(s)

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* 6. What is your estimate of the minimum and maximum number of doses needed?

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* 7. Please list date, start and end time of the event? Are you requesting a one-time or recurring event?

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* 8. What is the physical address where you plan to host the vaccination clinic?

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* 9. City and Zip/Postal Code

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* 10. Please describe the space that would be available for a vaccination clinic. Is this a large community room, multiple rooms, is parking available, etc.? Please include approximate square footage. Will tables and chairs, WiFi or cell service be available?

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* 11. How many staff members or volunteers will be available to assist? This might include assistance with traffic flow, communications, form completion, timekeeping, etc. (no medical training required.)

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* 12. Are there any other considerations about the space or population being served that you would like us to know?

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