Immunization Training Interest Form

In order to facilitate Ohio pharmacists' ability to broaden their scope of practice, OPA plans to continue to offer this valuable program. If you would be interested in attending a Pharmacist Training Program for Immunizations program, please complete the following secure form.* You will be contacted via the email provided on this form when the next program is scheduled.

Please use this form to update any incorrect fields below. Please use proper-case formatting as this information is what will appear in your record.

First Name Middle Last
OH Pharmacist License #
Preferred Email
(Notices about upcoming Immunization Training programming will be sent via email.)

Home Address

City State Zip
Home Phone Mobile
Please Check the Immunization Program Interest box below.
Immunization Program Interest
Please note: current OPA members have preferred registration status for this and other programs with limited seating. Thank you for your interest!
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   - denotes required fields