Proof of Vaccine
Please complete the form in its entirety to verify eligibility. All submissions are HIPAA compliant and confidential.
Today's Date:
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
How old are you?
Zip Code:
Enter zip code here
Demographic Information Required for Reporting
This information is confidential and will not be included with identifying information.
Please check ALL of the following that you identify as:
Male
Female
Transgender
Genderqueer, gender nonconforming, or nonbinary
Agender
I prefer not to answer
Other
Please check ALL of the following that you identify as:
Straight or heterosexual
Lesbian or gay
Bisexual
Queer or pansexual
Questioning
Don't know
I prefer not to answer
Other
Please check ALL of the following that you identify as:
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
I prefer not to answer
Do you identify as Hispanic or Latino/Latina/Latinx (check one)?
Yes
No
Is English your first/primary language (the main one you speak)?
Yes
No
If your answer is "No" then please list the first/main language other than English that you usually use below:
Which of the following COVID-19 vaccine dosages have you received on February 1, 2022 or AFTER?
*
1st Dose
2nd Dose
Booster
2nd Booster
None
Proof of vaccination is required to receive your $25 gas card. By checking a box(es) below you understand that the $25 gas card is only for vaccinations that occurred on February 1, 2022 and later. Please use the uploader below to upload proof of vaccination for the appropriate dosage.
1st Dose
2nd Dose
Booster
2nd Booster
File Upload: 1st Dose
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload: 2nd Dose
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload: Booster
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload: 2nd Booster
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I acknowledge and agree with the following: 1) Receiving a COVID-19 vaccination and participating in this incentive program is voluntary. 2) I acknowledge that this gift card may not be exchanged for cash, or used to purchase alcohol, tobacco, or weapons.
*
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Referral Program
Were you referred by someone to participate in the incentive program?
Yes
No
If yes, please enter their information below.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Know a family or friend who is vaccinated/boosted? Provide their contact information below. If they qualify, you'll receive a referral incentive.
Yes
No
If yes, please enter their information below.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Submit
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