Shoes for Shots

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SHOES FOR SHOTS

MEMBER INFORMATION:

Member's Full Name *

Member's Date of Birth (mm/dd/yyyy) *

Member's ID Number *

Mermber's Email Address *

Member's Phone Number *

Street Address *

City *

State *

Zip Code *

VACCINE DETAILS:

Date of Shot(s) *

Provider / Clinic Phone # *

Provider / Clinic Name *

SHOE INFORMATION:

Brand Option 1st Choice *

Brand Option 2nd Choice *

Brand Option 3rd Choice *

Acknowledgement & Consent

I confirm that the member listed above received the documented shot and I understand that the Shoes for Shots program offers a pair of shoes at no cost as an incentive. I acknowledge that this incentive is based on availability and styles and sizes may vary.

Acknowledgement * Yes No

Date *

Approval Date: June 12, 2025

Approval Code: HSH25286