VNA Workplace Flu Immunization Clinic Registration Form - Fall 2010

Schedule your clinic today! Please complete the following form, and once the request is received, our coordinator will contact you.

Company Name: *

Address: *

City: *

State: *

ZIP Code: *

Contact Name: *

Please enter your first and last name

Phone Number: *

E-Mail Address: *

Total Number of Employees in the Organization:

Schedule Preferences

Best Month:

Best Day of the Week:

Preferred Time of Day:

Workplace Information

Total Number of Immunizations:

Of this number, how many are adults 19 years of age and older?

Of this number, how many are children 18 years of age and younger?

Are family members/others invited?

Yes

I agree to a $50 site fee if less than 25 people attend:

Yes

I would like to schedule multiple sites:

Yes

Additional Information:

VNA – Visiting Nurse Association