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2. Please fill out all fields in the form below to help us best assist you in getting your free COVID prevention materials.
4. Name
5. Email Address
7. Organization
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. How would you like to receive your supplies?
    -- Select One --Please mail to the address on this formI would like to pick up at the Snohomish Health District building (3020 Rucker Avenue in Everett)
18. We will contact you by email or phone to confirm when your items have been mailed or when they are available for pick-up, depending on how you answered the previous question.
22. Please see images at bottom of form to help make your selection(s)
24. I'd like to request (multiple selections allowed)*

    1. #VaxUpSnoCo buttons (variety pack)
    2. Handwashing reminder stickers (quantity: 4)
    3. Please wear a cloth face cover window cling (quantity: 2)
    4. "Por favor use una cubierta facial de tela" adhesivo para ventanas (cantidad: 2)
    5. Fight illness posters (quantity: 2)
    6. Vaccine information rack cards and holder (English and Spanish)
26. If you would like to request more of the above items than the quantity listed, please specify below. We will provide additional supplies as long as they are available.
28. 
29. 
31. 
32. 
34. 
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field