This form is run by the Australian Vaccination-risks Network (AVN) to help collect interest for the Aussie Vaxxed Bus Tour.

Please fill out this form if you have an injury story, an unvaccinated story, or just want to know when the bus will be in your area.

Please do not complete this form more than once.

Question Title

* 1. Do you have a vaccine injury or unvaccinated story to share?

Question Title

* 2. Are you willing to share your story publicly on camera?

Question Title

* 3. Did you already share your story with Polly Tommey when the Vaxxed Team travelled to Australia? (You will still get the same chance as everyone else to share it again on the Aussie bus).

Question Title

* 4. What state do you live in?

Question Title

* 5. What is your postal code?

Question Title

* 6. What is your closest city or urban centre?

Question Title

* 7. How far are you able to drive to meet the Vaxxed Bus at a pit stop? (This will help us contact you if the bus is coming within your driving distance).

Question Title

* 8. Please provide a short summary of your story. (E.g. Which vaccines, what ages, type of injury. The shorter, the better).

Question Title

* 9. What is your name? (First & last name please)

Question Title

* 10. What is your email address?

Question Title

* 11. What is your phone number?

Question Title

* 12. Are you interested in volunteering to help coordinate for your area?

0 of 12 answered
 

T