"I'm Vaccinated" Bracelet Request Form

"I'm Vaccinated" Bracelet Request Form
Calls and confusion over the latest CDC COVID-19 guidelines led the Kansas City Shepherd’s Center to create an"I'M VACCINATED" bracelet.

KCSC thanks you for helping to alleviate some of the confusion over recent CDC masking guidelines by proudly wearing your "I'M VACCINATED" bracelet.

To request your bracelet, please complete and submit the form below.
Name*

First NameLast Name
Company (if applicable)
Email*
example@example.com
How did you hear about KCSC "I'm Vaccinated" bracelets?
Delivery*

I will pick-up at KCSC office (1111 W. 39th St., Ste.200, KCMO 64111)Please send by mail (must provide address below)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
I am requesting an "I'm Vaccinated" bracelet for:*

MyselfMy FamilyMy CompanyOther
Number Requested*
Individuals and Families

To maintain the integrity of the bracelets, individuals and families requesting bracelets must upload copies of the vaccination cards for each person receiving a bracelet.
File Upload

Cancelof
Companies

Each company distributing bracelets agrees to maintain the integrity of the bracelets, by verifying that every person receiving a bracelet has been vaccinated by showing a copy of their vaccination card.
Required*

I commit to verifying that every person given a bracelet has been vaccinated by verifying they have a vaccination card.
Should be Empty: