Leading By Example Sign-On Form

Supporting Organization Sign-On

By signing on to this initiative, our organization supports the goals of increasing awareness of the dangers of influenza and COVID-19 among adults with chronic health conditions and the benefits of annual vaccination, to improve public health and patient outcomes.
Name of Organization (as it should be listed) *
Organization Website *
Organization Twitter Handle
Name of Authorized Representative *

First Name Last Name
Title of Authorized Representative *
E-mail Address of Authorized Representative *
Phone Number

Area Code Phone Number
State *
Should be Empty:

Supporting Organization Sign-On