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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.

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

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

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* 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).

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* 4. What state do you live in?

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* 5. What is your postal code?

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

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* 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).

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

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

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* 10. What is your email address?

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* 11. What is your phone number?

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

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