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Mobile Clinic Event Request Form

Event Date *

*Please give 30 days advance notice.

Event Time *

Organization/Business Name *

Location of Event *

Address *

Address

Address 2

City

State

Zipcode

Phone *

Contact Names *

Contact Phone *

Contact Fax

Contact Fax
Contact Fax

Contact Email

How many VFC eligible children do you expect will come for immunizations? *

* We are Texas Vaccines for Children providers. For questions on eligibility, please call 832-824-6788.

Do you have the space for a 40-foot long, 14-foot high mobile clinic? *

Yes

Must be clear of low hanging wires and trees, steep inclines, and fire lanes/zones.

Are you able to provide a registration area in a climate-controlled area with one table and two chairs indoors and access to an electrical outlet for the mobile clinic staff? *

Yes

Have you had an immunization event before? If yes, how many children were immunized?

What other services will you offer at the event?

Can you provide a waiting area indoors for families waiting to be immunized? *

Yes

Will other immunization providers or mobile clinics be attending this event? *

Yes

How will you promote the event?

In the event of mobile clinic technical failure, would you be able to provide a room indoors to immunize children to avoid cancellation? *

Yes

PLEASE NOTE: We carefully consider all requests submitted throughout the year. Requests for the months of July and August will be reviewed after March 15th. Please keep in mind that early submissions do not always guarantee acceptance.

How will you promote the event? (mark all that apply) *

Fliers

Radio/TV

Door-to-door

Letter to parents

Other

Services

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Mobile Clinic Event Request Form