StaySafe Pop-up Interest Form

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Thank you for your interest in the StaySafe program! Please use this form to tell us a bit more about yourself and why you want to run a StaySafe Rapid Screening Pop-up.

Please double check your contact info! Incomplete application or application with incorrect email address will NOT be processed.

What is your name (first and last)? *

What is your email address? *

What is your phone number?

What is your age range? *

Under 14

14-18

18-25

25-35

35-50

50-65

65+

Have you previously been involved with rapid testing? *

Yes, I have previously volunteered with StaySafe

Yes, my company has implemented a rapid testing program

Yes, I have previously visited a StaySafe rapid testing location

Yes, I have previously visited a rapid testing location (not StaySafe)

Other:

Will your rapid screening pop-ups be open to the general public or for a private group only?

Open for the public

Private group only

Other:

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Briefly describe the group for whom you are looking to provide rapid screening. *

How frequently do you expect to run a rapid screening pop-up?

How many rapid tests do you expect to need for each pop-up?

Thank you for your submission. If accepted, you will receive an email with next steps within 72 hours (due to higher than normal volumes). In the meantime, if you have any questions please reach out to popups@staysafescreen.ca.

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