Medical Vaccine Volunteer Form – Ulster County COVID-19 Information

First Name *

Email *

Current Occupation / Profession *

No Occupation

Last Name *

Checkboxes

Submit your Medical License / Certification Number *

Medical License / Certification Number *

Upload your Medical License / Certificate *

Drop your file here or click here to upload

Accepted file types are .jpg, .jpeg and .png

Submit your CPR Certificate Number *

CPR Certification Number *

Upload your CPR Certificate *

Drop your file here or click here to upload

Accepted file types are .jpg, .jpeg and .png

Address *

Address Line 1

Address Line 2

City

State

Zip

Picture of the Front and Back of Your Driver’s License *

Drop your files here or click here to upload You can upload up to 2 files.

Accepted file types are .jpg, .jpeg and .png

Head shot picture of you (from the neck up) for your ID Badge *

Drop your file here or click here to upload

Accepted file types are .jpg, .jpeg and .png

Date of Birth *

Gender

Last 4 Digits Social Security # *

Name