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   Park County Public Health
   825 Clark Street
   Fairplay, CO 80440
   719-836-4161
6. Flu and COVID-19 Response Team Volunteer Sign-Up
8. Park County residents and neighbors need each other now more than ever. Given the demands of the COVID-19 pandemic, Public Health needs your help to deliver essential services to our communities. Join us today and be a part of the response team. Just fill out and submit this form and we will contact you about available opportunities. Medical and non-medical volunteer positions are available. Park County will be hosting multiple vaccine clinics in the coming weeks and months but we can’t do it without you’re help.
10. Email Address*
11. Phone Number*
13. First Name*
14. Last Name*
16. Where do you live?
    -- Select One --AlmaBaileyFairplayGuffeyHartselLake GeorgeTarryallOther
18. General Availability (Days/Times, Recurring Availability)
20. Are you currently a registered medical provider

    1. Yes
    2. No
21. If yes please indicate type
23. What would you like to work on?
    -- Select One --Medical Role – administering vaccine Screening ClinicAdministrative StaffOther
24. If other please please describe
26. Other Comments
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

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