Community Immunization Presentation Request Form
Immunize Nevada is your "one stop shop" for on-site and virtual immunization learning opportunities for clinical settings, educational institutions, conferences and community-based organizations! Please complete the fields below so that we're able to cater our presentation to your needs.
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* Required
Contact Name
*
Your answer
Name of Organization/Agency/Company
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
ZIP Code
*
Your answer
Date of Presentation
*
Your answer
Time of Presentation
*
Your answer
Location of presentation
*
In person*
Virtual
If you answered "in person" above, please provide the address of the facility at which you'd like us to present. (NOTE: Staff and public safety is of utmost priority for Immunize Nevada. Due to COVID-19 restrictions, we may not be able to provide an in person presentation, but will do our best to accommodate requests. Thank you.)
Your answer
Duration of Presentation
*
15-20 minutes
20-30 minutes
30 - 45 minutes
45 - 60 minutes
Other
If you selected "other" above, please let us know how long of a presentation it is that you're looking for.
Your answer
What topic would your audience like to learn more about? (Check all that apply)
*
Flu Vaccine
HPV Vaccine
Senior Vaccines
Vaccine Hesitancy
Immunize Nevada (organization overview)
Maternal Immunizations (Flu/Tdap)
Childhood/Adolescent Immunizations
Other
Required
If you selected "other" for the question above, please let us know what topic interests you.
Your answer
Do you have any other information regarding your audience that may be helpful for us to know?
Your answer
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