Flu Vaccination Submission

Flu Vaccination Submission

Thank you for staying safe this flu season! Submit your proof of flu vaccination received between 9/1/25-8/31/26 below to receive a $25 gift card. Limit one gift card per member, per fiscal year. Restrictions and limitations may apply.
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Member ID*
(9 digits)
Gender
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Apt. No.

CityState

Zip Code
Email*
example@example.com
Please verify that you are human*
Vaccination Date:*

MonthDayYear
Date
Proof of Vaccination (Example: clinic receipt, vaccination card, or immunization record)*

Cancelof
Gift card eligibility requires vaccination between 9/1/25 and 8/31/26.
Should be Empty: