Barry and Eaton Counties COVID-19 Vaccination Clinic Medical Personnel Volunteer Sign Up Form

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IF YOU ARE NOT CERTIFIED TO ADMINISTER VACCINE OR ARE NOT EMS OR OTHER MEDICAL PERSONNEL, please fill out the non-medical volunteer form which can be found on our website here: https://www.barryeatonhealth.org/covid-19-vaccine-information.

Please fill out the following information completely if you are interested in volunteering at one of our COVID-19 vaccination clinics.

Email *

Name *

Age *

Email *

Phone number *

Can we text you? *

Yes

Occupation *

Nurse

Doctor

EMS

Other:

My license is *

Current

Expired

Expired within the last 5 years

Other:

County in which you are willing/ able to volunteer *

Barry County

Eaton County

Both

How many days per month are you willing/ able to volunteer?

Are you certified to and comfortable with administering vaccine?

Yes

Other:

Clear selection

Although subject to change, morning shifts will range anywhere from 7am to noon, afternoon shifts anywhere from noon to 7pm.

Morning

Afternoon

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

We expect to receive enough vaccine to be able to vaccinate our volunteers. We need to prepare for volunteer vaccinations and need to collect the following information: *

I am ready to get my COVID-19 vaccination through the Barry-Eaton District Health Department on the first day I volunteer.

I will be obtaining my vaccine elsewhere (not through the Barry-Eaton District Health Department). I will sign a waiver form if I have not been vaccinated by the time I volunteer.

I need to learn more about the vaccine and would like to wait for a future date to get it. I will sign a waiver form so I can still volunteer.

Duties in which you are willing/ able to participate as a volunteer: *

Inoculate individuals

Monitor individuals for post-vaccine symptoms and side effects

Traffic control

Assist individuals with filling out forms (i.e. reading questions, helping with online registration, etc.)

Assemble informational packets

Symptom and temperature check

"Runners" (i.e. empty trash cans when needed, sit in while folks take a break, etc.)

Required

Are you able to work "in the elements" (i.e. rain, snow, cold, etc.)? *

Yes

Anything else we should know?

Submit

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