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VLC Engagement Request
Thank you for your interest in collaborating with the Vaccine Literacy Campaign. We look forward to providing your communities with tools for any of their vaccination needs. To get started, please provide us with details of your request with the form below. Thank you!
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* Indicates required question
Name of Organization
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Your answer
Brief Description of Organization
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Your answer
Organization's Zip Code
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Your answer
What services does your organization provide?
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Your answer
Primary Contact Name
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Your answer
Job Title
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Your answer
Email
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Your answer
Type of Engagement Requested
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Static Material Design (e.g., flier, social media post, PDFs, print materials, etc)
Capacity Building (e.g., train-the-trainer, professional development guide, toolkits, etc)
Direct Service Provision (e.g., presentation, information table, etc)
Quality improvement surveys (among your organization or community members)
Monthly bulletin of timely vaccine information (i.e, news, events, case studies, funding opportunities, etc)
Video/Recordings
Written Resources (e.g., blogs, Op-Eds, etc)
Other:
What is the topic for the engagement/event?
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Your answer
Target Audience
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Young Children (under 12 years old)
Teens/Young Adults (13-21)
Adults (general, 18+)
Older Adults (65+ years old )
Parents/Guardians
Asian American and Pacific Islander Communities
Black/ African American communities
Care providers/ community health workers
Faith Communities
Immigrant Communities
Immunocompromised Communities
Indigenous Communities
LGBTQ+
Differently-abled Communities
Individuals seeking employment
People experiencing homelessness
People with substance use disorders
Other:
Required
How many people does this engagement aim to reach?
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Your answer
Event Location
Virtual (i.e, Zoom, Teams, video conference)
Other:
Engagement Summary (please include any additional helpful details that would be pertinent to us including timeline/dates, restrictions, third parties involved, etc):
Your answer
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