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#YatesSaysYes2Vax Submission Form

  1. #YatesSaysYes2Vax
    Please complete this form if you would like to be featured in our #YatesSaysYes2Vax campaign. Please note: while all submissions will be considered, we cannot guarantee that your submission will be featured. Yates County reserves the right to refuse or alter submissions if required. If selected, your photo and the reason you got vaccinated could be featured on our social media platforms like this one
  2. Cody Salvatore (002)
  3. Enter a one or two word description of who you are. For example, you could write "Teacher", "Community Member", "Business Owner", or "Nurse".
  4. Enter a brief sentence explaining why you decided to get vaccinated.
  5. 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 Yates County Public Health will retain the ownership rights to these photographs, digital, or other images. If I request a copy, then Yates County Public Health will provide me with a digital copy. By submitting this form, I authorize Yates 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.
  6. Leave This Blank:

  7. This field is not part of the form submission.