UC Forms

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Vaccination POD Request

Fill out this form to request the County to come to your event to help vaccination guests! PLEASE NOTE: Filling out this form does not confirm a vaccination POD. Once completed, someone will reach out to you with any further steps.

Name of Event *

Location *

Date of Event *

Name of Point of Contact

Phone

Email *

Do you prefer to use a vaccination tent or use the County’s vaccination bus? *

Vaccination Tent
Vaccination Bus

Do you have a place inside that can handle 20 people sitting 6 feet apart? *

Yes
No
Other

Other Distancing

Is WiFi and electricity available? *

Yes
No
Other

Other Wifi

Do you have an EMT/EMS team available? *

Yes
No
Other

Other EMT

Can you assist with promotion of the vaccination pop-up? *

Website

(845) 340-3000 - 244 Fair Street, PO Box 1800, Kingston, NY 12402