Vaccine Clinic Forms

Thank you for volunteering your time at an upcoming George Mason University vaccine clinic. Your sign-up is not complete until you have completed and submitted the below form. Please direct any questions to safety@gmu.edu.

Name*
First Last
Date*
MM slash DD slash YYYY
Are you at least 18 years old?*
- Yes
- No
Because you are under 18, permission is required from a parent or legal guardian. Please download, print, and have a parent or guardian sign the following form. You willl then need to bring this form with you to the vaccine clinic.
MEMORANDUM FOR APPOINTMENT OF VOLUNTEERS
Email*
Enter Email Confirm Email
George Mason University Confidentiality Agreement

To download a PDF version of the below text, please click here

In consideration of my service as a volunteer at George Mason University, I may have access to sensitive or confidential information. This confidentiality agreement serves to verify that I have been made aware of the strict prohibition against inappropriate use of sensitive or confidential information. I understand that George Mason University expects me to hold in confidence any information I may become privy to in the course of my volunteer activities. Because this information is solely available to me as a result of my volunteer activities, internship or co-op, I will not discuss, use, forward, print, copy, photograph, record or otherwise disseminate any confidential or sensitive information that is given, shown, or available to me, or which otherwise comes to my attention, for purposes outside the legitimate scope of my work. Examples of confidential information that I may become aware of during the course of my volunteer activities at George Mason University include, but are not limited to:
- Information from or regarding the educational records of students, prospective students, alumni, employees, donors, associates and guests of the University
- Information regarding the physical or mental health or personal affairs of any of the aforementioned individuals.
- Information pertaining to George Mason University’s finances or budget, public relations plans or details, communications plans or details, or other internal or sensitive institutional information
- Information regarding access to Mason’s electronic files of any kind, and information pertaining to intellectual property of any kind, written or unwritten.
I further agree that during the term of my volunteer activities and following my separation with such association, I will be bound by this agreement. I am aware that failure to abide by this agreement may subject me to civil and criminal liability and disciplinary action up to and including my immediate termination from my position (and student disciplinary action that could result in suspension or expulsion.
Electronic Signature (George Mason University Confidentiality Agreement)*
- By checking here, I attest that I have read and agree to the Confidentiality Agreement above
Vaccine Interest Survey
If it is available, do you want the COVID-19 vaccine at the end of your last shift as a volunteer?*
- Yes
- No
Have you had a COVID-19 vaccine already?*
- Yes, first dose.
- No
Which vaccine have you received your first dose of?*
- Pfizer
- Moderna
Date of your first dose*
MM slash DD slash YYYY

George Mason University

Safety, Emergency, & Enterprise Risk Management

Vaccine Clinic Forms

George Mason University Confidentiality Agreement

Vaccine Interest Survey