Covid-19 Volunteer Vaccinator Application Form

COVID-19 Vaccine Clinics
Vaccinator Volunteer Application Form

Thank you for volunteering to administer COVID-19 vaccines.

Requirements: Cleveland-based LPN, Pharmacist, Physician or RN with an active license in good standing.

Clinical License Number # * 🛈

State in which you are licensed *

Clinical License Type *

LPN

Pharmacist

Physician

RN

Legal First Name *

Legal Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Additional Information: