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2. Please complete this form if you would like to be featured in our #SleeveUpSchuyler campaign. Please note: while all submissions will be considered, we cannot guarantee that your submission will be featured. The County reserves the right to refuse or alter submissions if required.
4. If selected, your photo and the reason you got vaccinated could be featured on our social media platforms in an image like this one.
   
6. First Name*
7. Last Name*
9. Email
10. Phone Number
12. Occupation
    Enter a one or two word description of who you are. For example, you could write "Teacher", "Community Member", "Business Owner", or "Nurse".
14. Reason you decided to get vaccinated
    Enter a brief sentence explaining why you decided to get vaccinated.
16. Photo upload
18. Photo consent
    By submitting this form, I'm verifying that I understand that photographs, digital, or other images will be recorded to document Public Health initiatives. I consent to this. I further understand that Schuyler County Public Health will retain the ownership rights to these photographs, digital, or other images. If I request a copy, then Schuyler County Public Health will provide me with a digital copy. By submitting this form, I authorize Schuyler County Public Health to use any photos that include a picture of me for the use of promotions / advertisements / press releases for Public Health initiatives and I understand the photos may appear on a web page, newsprint, pamphlet or brochure.
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field