Connecticut's ROCK THE SHOT Drawing

If you've received a COVID 19 vaccine, you can win front row seats to live concerts throughout the summer. All you need to do to enter is fill out this form. Winners will be contacted using the contact method provided below.

You must provide information that matches your vaccine record in order to win, and you must have received a first dose vaccination before you can complete this form. You can enter only once - submitting multiple entries can result in disqualification. Only Connecticut residents 18+ are eligible to enter.

* - Required Field

First Name*

Last Name*

Date of Birth*

Email address*

Phone number*

Street address of residence*

Town of residence*

Zip code of residence*

I affirm that I have received at least a first dose of a COVID vaccine. I understand this is a requirement to receive tickets in the drawing, and my prize will be withheld if I am found to not be vaccinated on the date of form submission.*

I will be fully vaccinated by that date and I understand

I consent for the Department of Public Health to access my vaccine records in order to verify my vaccination status if I am selected as a winner.*

I consent

I warrant and declare under penalty of perjury that the information included in this entry form is true in every respect. Submission of a false statement in this form is subject to the penalties of false statements pursuant to Conn. Gen. Stat. §53a-157b.*

I agree

DEPARTMENT OF PUBLIC HEALTH

DPH Submissions System

Connecticut's ROCK THE SHOT Drawing

* - Required Field

Which of the following concert raffles would you like to enter? Please select all that apply.*