EMS COVID Vaccinator Interest Form

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If you are interested in assisting with local vaccine clinics in southwest Virginia, please complete this form. Please note that vaccine administration is limited to Advanced Life Support (ALS) providers. By submitting this form, you agree to have your contact information shared with state/local agencies coordinating COVID vaccination in our region.

Email *

First Name *

Last Name *

Phone Number *

Please list your county of residence/work? You may list multiple counties. *

Certification Level *

EMT Basic

EMT Advanced

EMT Intermediate

Paramedic

Enter your EMS certification number *

EMS Agency Affiliation (please type NONE if not affiliated) *

EMS Agency Leader Name (type NONE if not affiliated) *

EMS Agency Leader Contact Info (Phone and Email) (type NONE if not affiliated) *

Submit

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