Trusted Messenger Interest Form

Trusted Messenger Interest Form

Adult Vaccination REACH Program
Thank you for your interest in volunteering to become a Trusted Messenger for our Adult Vaccination initiative!

Trusted Messengers work to:
- Assist with dispelling myths about vaccines and the viruses
- Help with upcoming event planning
- Attend events if possible
- Shares updates and event information in their community circles
- Attend quarterly meetings to discuss updates and events and provide feedback
- Are encouraged to recruit additional messengers
Please answer the following questions about the position, and we will be in touch with the next steps.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Gender

MaleFemaleN/A
Please take or upload a picture of yourself for your Trusted Messenger Profile.
Add a picture of yourself
Upload a picture of yourself

Browse Files

Cancelof
What is your race or ethnic background?

Black or African AmericanWhite or CaucasianHispanic or LatinoAmerican Indian/Alaska Native aloneOther
Why are you interested in volunteering as a Trusted Messenger?
What kind of Trusted Messengers can you be? (Please select all that apply)

Vax AmbassadorSocial MediaProfessional ExpertOther
Are you able to join our Trusted Messenger committee meetings every fourth Thursday of the month?

YesNoMaybe
Which of the following vaccines do you feel comfortable talking about or providing information on?

COVID-19Influenza (flu)Tdap/TdMMRChickenpoxShinglesHPVHepatitis A and BMeningococcalPneumococcal
What could you do as a messenger to assist with the project?
Which social media platforms do you use for learning or communication? Check all that apply.*

FacebookTwitterInstagramTikTokSnapchatOther
How frequently do you use social media?

EverydayA few times a weekA few times a monthLess frequently
Should be Empty: