Elkhart County Health Department: Medical Professional Volunteers Needed to Administer COVID-19 Vaccines at our Vaccine Clinic
Please complete this form if you are interested in volunteering with Elkhart County Health Department's COVID-19 vaccine clinic. In order to administer vaccines you must be a Registered Nurse (RN), Licensed Practical Nurse (LPN), Medical Doctor, or Emergency Medical Technician (EMT). Must be willing to submit for a background check. We will contact you as the needs arise.
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Full Name *
Date of Birth *
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Address *
Email (if you do not have one, type N/A) *
Phone Number *
Provide days and hours of availability. Schedule is subject to change. Clinic hours are Monday 1:00pm - 4:30pm; Thursday 8:30am-12:00pm. If you are not available during these days/hours, please specify the days/hours that you are available. *
Available with 24 hours notice? *
Are you a healthcare professional? *
Professional License Type (e.g. RN, MD)
Professional License Status
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Professional License Number and Expiration Date (e.g. #xxxx, 1/1/1111)
Professional Certifications or Specific Skillset
Other Language Abilities (besides English)
Previous Volunteer Experience
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