Thank you for your interest in assisting at our COVID-19 Vaccination Clinics!

Please note: This form is ONLY meant for individuals who have active Washington State medical licensure, authorizing them to administer vaccines, and who are not already employed by Virginia Mason.

Questions? Contact Virginia Mason Volunteer Services at

Contact Information

Emergency Contact

In the event of an emergency whom should we notify?

Medical Experience

Please answer the following questions based on your current Washington State medical licensure.

Email Communication Agreement

I agree that Virginia Mason may use email to communicate with me regarding my COVID-19 Vaccine Clinic shifts and/or scheduling.