Private GCVC Website - Request to Join

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Georgia Coalition for Vaccine Choice

Name ( First, Last) *

E-mail *

Are you already a member of the closed Facebook group, Georgia Coalition for Vaccine Choice? *

Yes

If you are on Facebook, what is your user name? *

Not on Facebook

Other:

The following information is required to become a GCVC Member. While GCVC membership is required to access the private Facebook group and website, it does not guarantee immediate access to the private Facebook group or website. A membership volunteer will review your request. If you choose not to become a member at this time, we ask you to please like our public Facebook page at https://www.facebook.com/VCHFGA/

I understand.

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I am a registered Georgia voter. *

Yes

Other:

To find your State Representative AND Senator districts, go to: https://openstates.org . Please list your STATE HOUSE REPRESENTATIVE (lower assembly) in the space provided. *

To find your State Representative AND Senator districts, go to: https://openstates.org . Please list your STATE SENATOR (upper assembly) in the space provided. *

To find your US Representative district, go to: http://www.house.gov/representatives/find/ . Please list your representative below. *

Are you in favor of vaccine choice? *

Yes

What does vaccine choice mean to you? *

Selective vaccination (accepting some, but not others)

Delaying or separating vaccination (deciding how vaccines are administered)

Not vaccinating at all (religious)

Not vaccinating at all (I or my child was injured)

Not vaccinating at all (other)

Why are you interested in joining GCVC ? *

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