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#ModernaVax2PH: Moderna Vaccines Release Campaign - Self Report/Consent Form
Use this form to:
(1) Share info on your participation (sent letters) for the #ModernaVax2PH Campaign
(2) Provide your consent to sign on to the letter FYLPRO will be sending. (Deadline Thurs, Apr 29 11:59EST)
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Email
*
Your email
Full Name:
*
Your answer
Organization or Affiliation:
*
Your answer
Location (City and State)
Your answer
Who did you reach out/send email/ letter to?
*
President Biden
Acting Administrator Gloria Steele
Secretary Antony Binken
BOTH U.S. Senators representing your state (provide name below)
Your House Representative (provide name below)
I want to want to sign-on to the FYLPRO letter
Required
Name of U.S. Senator/s:
ONLY IF you chose "BOTH U.S. Senators representing your state" above
Your answer
Name of House Representative:
ONLY IF you chose "Your House Representative" above
Your answer
When did you reach out/send email/ letter?
MM
/
DD
/
YYYY
Are you giving us your consent to sign-on your name in the letter that Filipino Young Leaders Program (FYLPRO) will be writing?
*
Deadline to sign-on: Thursday, Apr 29 11:59EST
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