Vaccination Outreach Partnership Interest Form
The goal of this effort is to build trust in the COVID-19 vaccines and increase access in our communities.

We hope to serve as a centralized platform to collect and share effective engagement strategies with a broad coalition of partners.

If you are interested in partnering or volunteering, please fill out this form and we will get in touch!
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Email *
First Name *
Last Name *
City *
State *
Phone Number *
Are you volunteering as an individual or organization? *
If you are volunteering with an organization, what is name of the organization?
What is your role in the organization
How are you interested in helping with vaccine outreach and education? (check all that apply)
If you responded "Other" in the Question above, please elaborate in your response below:
Link to social media accounts:
For Month of Action which will be from June 4-July 4, which of the action items are you able to commit to? You can check more than one:
If you selected "Other" above, please indicate what you can commit to.
What is the general outreach you have? You can provide rough estimates. For ex: number of calls you can make, number of followers on your social media account, etc. This information is being collected to gauge collective impact.
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