I Raise the Rates Community Champion Program Application Form

Indicates required field

Apply today to become an I Raise the Rates Community Champion and take the lead in promoting adult vaccine uptake in your community!

Space is limited. Your application does not guarantee a place in the I Raise the Rates Community Champion Program. The deadline to apply is October 6, 2023. Applicants who are accepted into the program will be notified by October 13, 2023.

First Name:

Last Name:

ACP Number:

Email Address:

Credentials:

What is your specialty/subspecialty?

In a few short sentences, please describe why would you like to become an I Raise the Rates Community Champion and what you hope to accomplish through participation in this program.

By completing this application, I understand that if selected for the I Raise the Rates Community Champion Program, I will be expected to attend the virtual orientation session (or view the recording), design and implement an action plan to promote immunizations in my community, attend at least two coaching sessions, and present final project report in March 2024.