VACCINE REWARD SIGNUP

GET VACCINATED

GET $100!


Registration for the $100 reward will remain open until September 30, 2021. Only individuals who have received their first dose between the dates of August 20, 2021, and September 19, 2021 are eligible to receive the reward.

In order to be eligible, Wisconsin residents ages 12 and older must receive their first dose at a vaccination site in Wisconsin, Michigan, or Minnesota between August 20, 2021, and September 19, 2021. Reward requests must be submitted by 11:59 p.m. CST on September 30, 2021. Please allow six to eight weeks to receive your U.S. Bank Rewards Card in the mail.

For more information, visit https://www.dhs.wisconsin.gov/covid-19/100.htm.

Healthcare Privacy Notice

The Wisconsin Department of Health Services (DHS) is giving one $100 U.S. Bank Rewards Card to Wisconsin residents ages 12 and older who receive their first COVID-19 vaccine from a Wisconsin vaccination provider from August 20, 2021, through September 19, 2021. Everyone who is eligible to receive the free COVID-19 vaccine is eligible to receive this gift card, regardless of insurance, ID, or citizenship.

To receive this $100 U.S. Bank Rewards Card, you must provide the personal information requested on the form below, including information about when you received the first dose of a COVID-19 vaccine.

Your personal information is private healthcare information under Wisconsin Statute section 146.82. We collect this information to verify your eligibility to receive a reward through this program and to send you the reward you requested. Your private information will only be shared with DHS employees and contractors in order to determine eligibility. If you are eligible for the reward, then DHS will share your name and mailing address with U.S. Bank, so that U.S. Bank can mail you a U.S. Bank Rewards Card.

The U.S. Bank Rewards Card cannot be reloaded with additional funds. It cannot be used at an ATM. No cash access. Terms and conditions, including fees, apply. The Rewards Card is issued by U.S. Bank National Association pursuant to a license from Visa U.S.A. Inc. ©2021 U.S. Bank.

Verification

DHS will verify immunization by matching the data you provide with the data available in the Wisconsin Immunization Registry (WIR). If you have locked your record in WIR for any reason, you will not be eligible to receive this reward as we will not be able to verify your vaccination. Your name and date of birth must match the information in the Wisconsin Immunization Registry in order for DHS to be able to confirm that you were immunized.

YOU MUST BE THE AGE OF 18 OR OLDER AT THE TIME OF VACCINATION TO FILL OUT THIS FORM.

If you are between the age of 12 and 17, please have your parent or guardian fill out this form. A person acting as a parent or guardian may fill out the form for an unaccompanied youth.

REQUIRED FIELDS*

Vaccine Recipient Information:

Please provide the address where you prefer U.S. Bank to mail you the U.S. Bank Rewards Card.

Your name and date of birth must match the information in the Wisconsin Immunization Registry in order for DHS to be able to confirm that you were immunized.

A valid email address is required to register. If you do not have a valid email address or you need assistance filling out the form, call 844-684-1064, Monday through Sunday, 7 a.m. to 7 p.m. CST.

A valid email address is required to register.


Tell Us About Your Vaccination

We need some information about your COVID-19 vaccination to verify program eligibility.


Only one incentive per qualifying individual is permitted. Individuals providing false information could be denied the incentive and could be subject to civil or criminal penalties available under other applicable laws.