Name
*
First Name
Last Name
Your age
*
Your phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your email address
*
example@example.com
Name of the person you helped
*
First Name
Last Name
Age of the person you helped
*
Briefly describe your relationship to the person you helped.
*
Date you helped the person get their vaccine
*
-
Month
-
Day
Year
Date
Which vaccination site did you go to?
*
Have you received your vaccine?
*
Yes, before I accompanied this person.
Yes, I received the vaccine with the person I accompanied.
No, I have not been vaccinated yet.
Please upload a photo of yourself and the person you accompanied at the vaccination site. Do NOT upload photos of vaccination cards/records.
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Please DO NOT upload a photo of any vaccination cards or records. Examples of acceptable photos: a photo with an "I got vaccinated" sticker, together at the vaccine site, showing the bandage on their arm, etc.
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Briefly describe your experience helping another person receive the vaccine.
*
How did you hear about Dinner and a Dose?
Do we have your permission to use your picture and/or quotes in our media communications?
*
Yes
Yes, but make me anonymous
No
How would you like to receive your $25 DoorDash giftcard?
*
By text
By email
Other
Would you like to subscribe to St. Barnabas's email newsletter?
Yes!
No
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