2023 Highway to Health Expo
Member's Name:
*
First Name
Last Name
Shirt Size for Member only! Dependents are not eligible to receive a free t-shirt
*
Please Select
Large
XL
2XL
3XL
Please provide the member's shirt size for FREE Highway to Health Expo t-shirt. Must be in attendance to receive!
Shirt Size for Spouse (if applicable) only! Dependents are not eligible to receive a free t-shirt
*
Please Select
Large
XL
2XL
3XL
Not Applicable
Please provide your spouse's shirt size (if applicable) for FREE Highway to Health Expo t-shirt. Must be in attendance to receive!
Best Contact Number:
*
Please enter a valid phone number.
MOE ID Number
*
Please note that this is not your Union Registration Number! The MOE ID number is a 9-digit number that can be found on your Medical ID card and your MOE Vendor card.
Member's Email Address:
*
example@example.com
How many eligible adults* (ages 18 and older) from your family will be in attendance for this event:
*
*Please include everyone over the age of 18, even if they are not planning on receiving a free service.
How many eligible children* (under the age of 18) from your family will be in attendance for this event:
*
*Please include everyone under the age of 18, even if they are not planning on receiving a free service. If none, please enter a "0".
Would you or anyone in your family like to get a flu shot?
*
Please Select
Yes
No
If yes, please indicate which flu shot and the number of flu shots you are requesting for you and your family.
1 Flu Shot
2 Flu Shots
3 Flu Shots
Other:
Please indicate the quantity of flu shots needed.
Regular Flu Shot
(Available for ages 3 & older)
High Dose Flu Shot
(For ages 65 & older only)
Egg Free Flu Shot
Submit
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