Vaccination Volunteers Needed

Credentials are Required

Thank you for your willingness to help administer the COVID-19 vaccination at UAMS.

Before filling out the form below, you will need to review the following files.

COVID-19 Waiver Form Download

Fire and Safety RACE – PASS Download

Photography Release Agreement Download

Service Description COVID-19 Vaccine Clinic 2021 Download

UAMS Confidentiality Policy 2.1.01 Download

UAMS HIPAA Level I Training Form Download

UAMS Incident Injury Reporting Policy 11.4.01 Download

What is Culture Smart Download

Volunteer Contract Download

Volunteer Handbook (Revised 01.31.2018)Download

Once the files have been reviewed, electronically sign and submit your Confidentiality Agreement and then fill out the form below.

COVID-19 Vaccine Volunteers

Name * Required
First Last
Address * Required
Street Address Address Line 2 City State ZIP Code
Phone * Required
Email * Required
Certification * Required
Certification License # * Required
Digital Signature * Required
By checking this box, I acknowledge that I have read each document in its entirety and that I am choosing to sign this form digitally.
- This form has been digitally signed.