Alberta COVID-19 Pharmacy Immunization Program

Find out more information about participating pharmacies.

Application form

COVID Community Roots Program

Note: Asterisks [*] indicate required information.

Organization information

Please enter your organization name
Please enter your organization website
Please enter your city/town.
Please select your province.
Please enter your postal code.

Contact information

Please enter contact person's name.
Please enter key contact person's job title.
Please enter a valid phone number for contact.
Please enter a valid contact email address.
Please enter sponsor organization's name.
Please enter sponsorship contact person's name.
Please enter sponsorship contact's job title.
Please enter a valid sponsorship contact phone number.
Please enter a valid sponsorship contact email address.

Expression of need

Please fill out this section to continue.
Please enter your intended start date.
Please enter town/municipality.
Please enter anticipated number of people served.
Please fill out this question to continue.


Please enter your requested total funding.

Please provide a breakdown of your budget.

Please enter your supplies budget.
Please enter your administration budget.
Please enter service costs.

Please note the following expenses are ineligible for funding :

  • Funding for shelter,
  • Hospital or medical services,
  • Capital projects, and
  • Costs to sustain an organization outside of the initiative in question.


I confirm that this application in its entirety is truthful to the best of my knowledge.

Please enter applicant's name.
Please enter applicant's name.