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House of Worship Vaccine Request

Faith leaders who would like to request that the COVID-19 vaccine be distributed at their place of worship should fill out the form below. Due to limited supply and logistical constraints, priority will be given to places of worship that can utilize a minimum of 300 doses. Faith leaders are encouraged to partner with other leaders in their community in order to serve the minimum threshold.
This question requires a valid email address.
Duration of Proposed Vaccination Site *This question is required.
Facility or area where vaccinations would occur *This question is required.
Americans with Disabilities Act compliant (wheelchair accessible). *This question is required.