Don't Wait. Vaccinate! Entry Form

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Don't Wait. Vaccinate! Entry Form

You must have received all doses of the COVID-19 vaccine to be eligible - one shot of Johnson & Johnson or two shots of Pfizer or Moderna. Proof of vaccination will be required if you received the vaccine outside Louisiana.

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Full Name *

Your answer

W Number *

Your answer

Cell Phone Number *

Your answer

Date of Birth *

MM

/

DD

/

YYYY

I affirm that I have received a full dose of a vaccine (two doses of MOderna or Pfizer, a single dose of Johnson and Johnson). *

Yes

No

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