Healthier You! Flu Fighter Submission Form Take action this winter by getting the flu shot and capturing your Flu Fighter moment with a photo of yourself, your arm bandage, sticker, or vaccine record. Fill out the form below with your photo to claim a FREE Healthier You! Wellness Kit. When you’re finished, hit submit and celebrate protecting your health like a true Flu Fighter! Need Assistance? Email us at healthyhelp@cfhp.com.Name(Required) First Last Member ID#(Required)Shipping Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Date you got your flu shot.(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Where did you get your flu shot?(Required)Doctor's OfficePharmacyRetail Store (Target, Walmart, HEB, etc.)Drive-Thru Flu EventOtherUpload proof of you receiving your flu shot (a picture of you receiving the flu shot, your arm after the shot with a bandage, flu shot sticker, or vaccine record).(Required) Drop files here or Select files Accepted file types: jpg, png, Max. file size: 50 MB, Max. files: 3. Consent(Required) I agree to the Community First Media/Minor Appearance Policy.I, the parent or legal guardian, hereby grant Community First Health Plans, Inc. (hereinafter referred to as “Community First”), its employees, staff, licensees, assignees, designees, successors, affiliated healthcare providers, contractors, and legal representatives, the irrevocable right to interview me/my child(ren), use my/my child(ren)’s likeness and information, and publish information about me/my child(ren) in an appropriate manner for the below-mentioned project. This grant includes any legal use in perpetuity, such as publications, fundraising, advertising, copyrights, title and interest, trade, marketing, publicity, promotion, web content, illustration, education, or publication in print, broadcast, and electronic media, including social media and all other formats. It encompasses the use of my/my child(ren)’s likeness, name, voice, and appearance in photographs, video footage, and digital media. I understand and agree that any photographs, videos, or publications using my/my child(ren)’s likeness and information shall have unlimited usage rights and casting rights, becoming the property of Community First. I waive any right to inspect or approve the finished product, including written copy, created in relation to the above-mentioned project. I approve the taking and use of photographs, audio and/or videos, or other related materials without limitation, as described above. I understand that I/my child(ren) may be identified in any use of the materials. I acknowledge that I/my child(ren) will not receive any compensation for the use of these materials. I understand and agree that this authorization remains valid unless and until I cancel it in writing. Furthermore, I acknowledge that once the release of my/my child(ren)’s likeness or use of this information is disclosed, it is no longer protected by state or federal law. I retain the right to cancel this authorization at any time by contacting Community First in writing at communications2@cfhp.com. However, I understand that the cancellation will not apply to any use or release of my/my child(ren)’s likeness that has already occurred. I acknowledge that my/my child(ren)’s participation with Community First is voluntary. I understand that Community First and its affiliated healthcare providers cannot require me to sign this authorization as a condition for receiving treatment, making payments on any bills, or obtaining enrollment or eligibility in any health insurance plan. I may request a signed copy of this authorization for my/my child(ren)’s records. By signing this authorization, I release, indemnify, and hold harmless Community First, its staff, employees, contractors, and affiliated healthcare providers from any and all claims or causes of action that may arise from the release or use of this information and/or my/my child(ren)’s likeness. The terms of this authorization shall commence on the date signed and be without limitation. I CONFIRM THAT I AM OF FULL LEGAL AGE, HAVE READ THIS AUTHORIZATION FORM FULLY, UNDERSTAND ITS CONTENTS, AND AM SIGNING IT FREELY AND VOLUNTARILY. AS THE PARENT OR LEGAL GUARDIAN OF THE ABOVE u0002MENTIONED CHILD(REN), WE SHALL ALL BE BOUND BY THE TERMS OF THIS APPEARANCE RELEASE Δ
