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Volunteer Form

  1. Vaccine Distribution Volunteer Sign Up
    If you have a valid medical license and would like to help distribute the COVID-19 vaccine, please fill out the form below. Pottawatomie County will contact you to organize the effort.
  2. This is NOT the Vaccine Interest Form. Please follow the below link to sign-up for the vaccine. https://pottcounty.govbuilt.com/vaccinesignup
  3. Are you currently licensed in the State of Kansas?
  4. Thank You for Volunteering
  5. Leave This Blank:

  6. This field is not part of the form submission.