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> COVID19 Vaccination Clinic Pop-up Request Form

2019 Novel Coronavirus (COVID-19)
Vaccination Clinic Request


THE HEALTH AND WELL-BEING of our community is our top priority. Tompkins County Health Department (TCHD) is working closely with community partners to prevent and respond to the evolving novel Coronavirus (COVID-19) outbreak.


Vaccine Icon -- Vaccines Protect Us All #7A015B

As eligibility and supply of the COVID-19 vaccine expands, the Tompkins County Health Department (TCHD) is continuing to plan an equitable rollout to residents.

The Tompkins County Health Department plans to continue offering small pop-up COVID-19 vaccination clinics around Tompkins County, and is gauging interest from local organizations who may want to offer an on-site clinic for stakeholders who are over the age of 18. These clinics will offer convenient, on-site appointments for individuals who work with you or are a part of your organization or group. The Health Department would also have information available for you beforehand and during the event on the safety and efficacy of vaccines. We are requesting that you fill out this form if you anticipate ten or more individuals who would plan to receive a vaccination at your site

Some examples of who might use this form to request a clinic:

  • Employers
  • Fraternal Organizations
  • Community-Based Organizations
  • Volunteer organizations
  • Faith-Based Organizations or Places of Worship
  • Community Gatherings.

Filling out this form does not guarantee you a clinic and we are unable to accommodate requests for a specific vaccine.  A representative from the Tompkins County Health Department will contact you for more information and/or to plan a clinic at your location.

If you would like to support your workforce or community getting vaccinated through other clinics and local opportunities please visit our resources page and encourage use of the local vaccine registry

Please subscribe to the Health Department's email list to receive more updates on Phases, vaccinations, and more.

Register Here 

If your browser does not display the registry form below the line, please call 2-1-1 (1-877-211-8667) to provide the same information requested in the form. 

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