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™ Campaign Plank Implementation *

My organization commits to implementing “campaign planks” based on our areas of interest and resources available. Rise to Immunize™ will follow up with a brief survey at campaign launch for benchmarking purposes.*

Rise to Immunize™ Data Reporting *

Please select your data track below: *

Basic Track (influenza, pneumococcal) )

Core Track (influenza, pneumococcal, Td/Tdap, zoster, reporting measures both individually and as a bundle)

To be determined – campaign staff will contact me to discuss data track options

Clear Selection

Rise to Immunize™ Campaign Commitment *

On behalf of my organization, I commit to joining the Rise to Immunize™ campaign.*

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.*

Fields marked with * are required.

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