COVID-19 Vaccination Clinic Request

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Please fill out the form below if you are interested in hosting a COVID-19 vaccine clinic within the Brown County jurisdiction (excludes De Pere & Oneida Nation). Requests will be handled on a first come first serve basis. Someone from Brown County Public Health will be following up to obtain more detailed information regarding your event request. Thank you!

Please provide your name. *

Please provide your email and/or phone number so that we can contact you. *

What organization(s) do you represent?

What kind of clinic are you interested in? *

On-Site Clinic (Within your place of business or other indoor setting)

Please provide me with local vaccinator clinic opportunities & services

No Preference

Where are you interested in holding a vaccine clinic?

Is there a specific date or time frame you had in mind? Please let us know if there is any flexibility with your request or state "no preference".

Are you requesting an open or closed clinic?

We would like this event to be open to the public

We would like this event to be invite only

Clear selection

How many people do you anticipate will get vaccinated at this event?

What vaccine type are you requesting? *

Pfizer (First & Second Doses)

Johnson & Johnson (One Dose)

Moderna (First & Second Doses)

Booster Doses (Pfizer)

Booster Doses (Johnson & Johnson)

Booster Doses (Moderna)

Pediatric Ages 5-11 (Pfizer Only)

Pediatric Ages 12 & up (Pfizer Only)

Required

Will you be needing interpreting services at this event?

Yes

Unsure

Clear selection

Is there anything else you would like us to know about this event request?

Submit

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