COVID-19 Vaccine Volunteer Intake Form

SEIU Healthcare 1199NW is working in partnership with Washington state leaders, Gov. Jay Inslee’s office, fellow unions and businesses to coordinate COVID-19 vaccine distribution efforts. If you are a current or former healthcare worker interested in volunteering to give the vaccine, please fill out the Vaccine Volunteer intake form below.

Please note: The Washington State Department of Health has not yet issued definitive guidance on qualifications to become an authorized vaccine provider. If necessary, the state may call on those who have inactive licenses to assist in vaccine administration pending additional vetting.

Name *

First

Last

Email *

Phone *

By submitting this form and providing my phone number and email, I understand that SEIU may contact me to gather additional licensure information and to discuss vaccination assignment details.

Race

Preferred Pronouns

Zip Code *

I am a current or former... *

Are your healthcare credentials active? *

Active
Lapsed
Not sure

Are your credentials from Washington state?

Would you be willing to drive more than 25 miles for a vaccination assignment?

Yes
No
Not sure

If you are a current or former member of SEIU Healthcare 1199NW, please select your employer