VOICES FOR VACCINES

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Required Information VFV Privacy Policy

YES, I support immunization and want to join Voices For Vaccines.

Salutation

First

M.I.

Last

Primary Address:

Street, line 1

Street, line 2

This is my home address
This is my work address

City

State/Province

Zip/Postal Code

Region (if applicable
outside US/Canada)

Country

Primary phone

Extension

Personal cell

Home landline

Work landline

Work cell

Primary email

Home

Work

Other

Please create a username and password for you to use if you need to check or update your VFV membership information in the future.

Username

Security Question

Password

Answer

In the interest of protecting children’s privacy, we do not accept membership applications from children under 13. Parents, if you have a child under 13 who wants to join, please contact us via e-mail. By checking this box, you affirm that you are at least 13 years old:

You can stop here and join right now, but we’d appreciate having a little more information about you, so if you have another minute, please continue down the page – there’s another “Join!” button at the end.

Please check all that apply:

I am a parent.

I am a grandparent.

I am a healthcare worker.

I am a medical researcher.

I am a journalist or author.

I am an educator.

I work in government.

I am a student.

Degree program or field of study

Other

Please specify

I have experience with serious illness or disability due to vaccine-preventable disease in:

Myself

A friend

A patient of mine

Other

Please specify

Personal Profile

Home Address:

Street, line 1

Street, line 2

We ask for your home address because that’s what determines which state laws affect you and which media cover your residence.

City

State/Province

Zip/Postal Code

Region (if applicable
outside US/Canada)

Country

Home phone

Landline

Cell

Alternate Phone or International Dialing Instructions

Home fax:

Home email:

Professional Profile

Title:

Organization Name:

Work address:

Street, line 1

Street, line 2

Many members of Voices For Vaccines work in disciplines related to vaccines. We provide these fields so they can let us know about that involvement – but you certainly don’t have to be a professional to join, and we are interested know about our member’s backgrounds whether or not they’re vaccine-related.

City

State/Province

Zip/Postal Code

Region (if applicable
outside US/Canada)

Country

Work phone:

Primary

Extension

Alternate Phone or International Dialing Instructions

Work fax:

Work email:

Other email addresses at which you would like to receive VFV messages:

If your preferred mailing address is outside the U.S. or Canada, please type it in the box below as it should appear on an envelope.

In the future, Voices For Vaccines may create and publish a list of member’s names and the states where they live in order to demonstrate the broad base of support for immunization. Check this box if you give permission for your name to be included in such a list

Do you have a personal story or case report to share? This could be about how a vaccine-preventable disease affected you or someone close to you, something you experienced as a healthcare worker, the origin of your interest in vaccines, or your thoughts about a vaccine issue.

This narrative can be published on the VFV web site with my name and the state where I live.
This narrative can be published, but please identify me only by my initials and state.
This is for VFV’s information only.
Please contact me about sharing this narrative.

Vaccine supply

Vaccine safety

Vaccine handling and storage

Exemptions from vaccination

Vaccine financing

Administering vaccine

Travel vaccination

Immunization coalitions

Communication strategies

Tropical medicine

Vaccine development

Other (describe)

Do you have a background or expertise that might be valuable to VFV? This could be writing, public speaking, fundraising, event planning, communications technology, or other skills.

If you’ve already joined, you can check the information we have on file for you and update it if necessary. Contact our office if you’re unable to locate your record.