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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
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Your email
First Name
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Your answer
Last Name
*
Your answer
City
*
Your answer
State
*
Your answer
Phone Number
*
Your answer
Are you volunteering as an individual or organization?
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Individual
Organization
If you are volunteering with an organization, what is name of the organization?
Your answer
What is your role in the organization
Your answer
How are you interested in helping with vaccine outreach and education? (check all that apply)
Receiving and/or amplifying resources and content from AMHP
Write op-eds
Develop infographics
Produce short videos
Host webinar for community members
Translate graphics and/or content
Other: ____
If you responded "Other" in the Question above, please elaborate in your response below:
Your answer
Link to social media accounts:
Your answer
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:
Canvas
Phone calls
Texting
Having a booth at a grocery store, library, salon, barber shop, park, etc.
Other
If you selected "Other" above, please indicate what you can commit to.
Your answer
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.
Your answer
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