Vaccine Fund UK and Ireland Registration Form

Vaccine Fund UK and Ireland Registration Form
Current balance: £60

Please use this information when thinking about which vaccine to select.
The Vaccine Fund UK & Ireland are looking to vaccinate disadvantaged people who don't have access to COVID vaccines. We are a group of two disabled individuals based in England and Ireland so we ask for patience in waiting for a response.
- We have limited funds therefore, we may not be able to fulfil your request but we will do our best to direct you to services who may be able to support you.
- We ask that if you're applying for you and another person that you use different names so we can differentiate between each application.
- Please avoid multiple applications with the same details so we can mitigate confusion.
If you need support filling in the form, please email us at vaccinefund@proton.me
Please enter your details
Name

First NameLast Name
Email
example@example.com
Verify your email
Phone Number
Please enter a valid UK phone number.Format: (+44)0000000000.
Signal Username
If you'd prefer, enter your Signal Username
Vaccine Choice

Choose between the flu and COVID vaccine. Please note that have limited funds so you may be put onto a waiting list to be notified when we receive sufficient funds.
Which vaccine do you need?
Due to limited funds, we can only offer either COVID/Flu to ensure more people can get access to vaccines

Example of Marginalisation

As we are working to prioritise vaccines for the most marginalised in our community, please list examples of your marginalisation
Please explain
Proof of Vaccine Booking/Purchase

Please upload a screenshot of your covid vaccination booking
Upload File

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Proof of Address

We require this to prove your location is in the UK and Ireland. This can be a bill, an appointment letter etc. Please don't upload anything you don't feel comfortable sharing. Our systems are encrypted, and once we have verified them, we delete the file from our system. Please reference our Privacy Policy for more.
Upload File

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Payment Details

Please enter your payment details
Paypal, Revolut, Bank Details etc...
Personal Data Privacy Statement

Vaccine Fund UK and Ireland are committed to your privacy. We will not share your data with third parties. We use this information as verification of your identity, in order to send the funds as quickly as possible. Subsequently, when we have verified the information and the funds have been sent to you we will delete your personal data within 30 days of acquiring them.
Privacy Policy
Do you agree to the above statement
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Current balance: £60