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Immunization Can Be Your Chance to Win a Wii™!

A parent or guardian must complete this form to enter the raffle to win a Nintendo® Wii™.

After your child has seen his or her health care provider and received the recommended immunizations or has been told he/she is already fully immunized, you will be entered into a raffle to win a Nintendo Wii, or one of our other great prizes.* In November 2008, one Nintendo Wii will be raffled off to those that meet the immunization requirements. In addition other great prizes will be distributed starting in September. Supply is limited.

We will contact you if you are the winner.

I, 
  Parent Guardian First Name Last Name
certify that my child  
Child's First Name Last Name  

is age 11 – 13, has visited a Personal Choice®/Keystone Plan health care provider, and has either received recommended immunization(s) (such as those for human papilloma virus (HPV), meningococcal, tetanus, diphtheria toxoids, acellular pertussis (Tdap), mumps, measles, rubella, Hepatitis B, and varicella) or been told that he/she is fully immunized. I currently have health insurance coverage provided by Independence Blue Cross (IBC).
Provider's Name Date of Vaccine (mm/dd/yy) Child's Date of Birth (mm/dd/yy)
Independence Blue Cross Identification Number (from my ID Card)
Street Address
City State Zip Code
Phone Email (parent)

*Only children age 11 – 13 who are enrolled in an Independence Blue Cross health plan on the date this application is received are eligible. IBC reserves the right to determine eligibility and all decisions will be final.

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