Rise to Immunize® Campaign Enrollment Form

For guidance on identifying campaign points of contact, visit our website.

For questions or troubleshooting, please contact RiseToImmunize@amga.org.

Your Contact Information (Individual Completing Form)*

Organization: *

City: *

State: *

Name: *

Title: *

Email: *

Phone:

Rise to Immunize Contacts:*

Primary Contact: *

Title: *

Email: *

Quality Contact: *

Title: *

Email: *

Data/IT Contact: *

Title: *

Email: *

Marketing/PR Contact: *

Title: *

Email: *

Rise to Immunize Data Reporting: *

Please select your data track and/or any additional measures below (To select more than one option, hold ctrl and click all desired options.): *

Rise to Immunize Campaign Plank Implementation:*

My organization commits to implementing “campaign planks” based on our areas of interest and resources available. Rise to Immunize will field an annual survey to learn more about what campaign planks you are implementing.*

I grant AMGA Foundation permission to list my organization’s name in Rise to Immunize promotional materials, including print and online advertisements, website, articles, and press releases.*

Your form submission WILL be encrypted using SSL to ensure your privacy.