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Campaign to Get COVID-19 Vaccines Out in Communities of Color
Over 1,200 black and brown people have been vaccinated so far due to this campaign spearheaded by the African American Pastors’ Council. Thank you for your help.
Let’s keep it going…Join the Community Campaign to Get COVID-19 Vaccines Out in Communities of Color
- See the attached flyers and complete an interest form for yourself and/or someone you know, especially an older person or someone who does not have access to a computer.
- Sign-up to volunteer to make phone calls or work on the day of vaccine events. Email Seirra Winn: firstname.lastname@example.org or call 434-984-6220 and leave a message.
- COVID VACCINE INTEREST FORM
First, Middle, Last Name: ______________________________
Birth Date: ________________________
Address (Not PO Box): __________________________________________
City: _________________ Zip Code: ___________
Gender: ___ Male ___ Female ___ Other: ____________
Race (Check all that apply):
___American Indian/Alaskan Native ___ Asian ___ Black or African American
___Hawaiian Native or Other Pacific Islander ___ White ___ Other
Are you Hispanic/Latino? ___ Yes ___ No
Home Phone: __________________ Cell Phone: ___________________
Email address: __________________
What phase are you in?
___ Phase 1A: Frontline Healthcare Workers
___ Phase 1B: Employees of Essential Workers
___ Phase 1B: Individuals Age 65+
___ Phase 1B: Individuals Ages 16-64 with High Risk Medical Conditions
I consent to receive vaccination information or reminders by (Check all that apply):
___ Text Message ___ Email
Return forms to your church/community organization contact person
Sentara Starr Hill Health Center
At the Jefferson School City Center
233 4th Street NW, Second Floor Room 255A
Charlottesville, Virginia 22903
By email to: Setour Dillard, RN, Integrated Care Manager, email@example.com