Community/Non-Profit Organization Flu Vaccine Voucher Request Form
DuPage Health Coalition hopes to provide flu vaccine vouchers to uninsured individuals living in DuPage County. Each individual who intends to receive a flu vaccine through this program will need their own voucher. These flu vouchers can be redeemed at any Jewel Osco location and no appointment is necessary. Please note that only those aged 3 and older can receive their flu vaccine from Jewel Osco. For more information about the flu vaccine voucher program, please visit: www.accessdupage.org/flu
Name of your Agency
Name of Person Submitting Request
Address (where vouchers will be sent)
Street Address Line 2
State / Province
Postal / Zip Code
I would like to request __ flu vaccine vouchers for clients
May we identify your organization as a recipient of flu vaccine vouchers?
Click here to signal agreement that flu vaccine vouchers, if received, will be provided to people living or working in DuPage County.
Click here to signal agreement that your agency will provide flu vouchers, if received, at no cost to recipients.
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