MMBBAA FFLLUU SSHHOOTTSS && HHEEAALLTTHH FFAAIIRR

FFLLUU SSHHOOTTSS $$1155..0000 eeaacchh

FOR ALL MBA MEMBERS, EMPLOYEES AND THEIR FAMILIES

Thursday – October 28th, 2010 3:00 P.M. – 6:00 P.M.

Marin Builders Association, 660 Las Gallinas Avenue, San Rafael

FLU SHOT SIGN-UPS ARE REQUIRED IN ADVANCE Refreshments will be provided.

The Sign-Up DEADLINE is Friday - October 22nd so act now!

Our Benefits Consultant Chelsea Sabre Lee will be on hand to answer questions and discuss our health plan program.

IMPORTANT: If you have a history of hypersensitivity to eggs or egg products, do not sign up for a flu shot. Women in the first trimester of pregnancy can not have a flu shot; second and third trimester must have a doctor’s note. Due to liability the flu shot will not be administered to anyone under age 18.

***REGISTRATION FORM*** Please complete & return no later than Friday, October 22nd to:

MBA, 660 Las Gallinas Ave., San Rafael, CA 94903 or Fax to (415) 462-1225

Please print all names clearly. Attach a list of additional names if needed.

Company Name____________________________ Phone ______________ Fax _____________ Name___________________________________( ) Flu Shot ($15 ea.) ( ) Pneumonia ($45 ea.)

Name___________________________________( ) Flu Shot ($15 ea.) ( ) Pneumonia ($45 ea.)

Name___________________________________( ) Flu Shot ($15 ea.) ( ) Pneumonia ($45 ea.)

Name___________________________________( ) Flu Shot ($15 ea.) ( ) Pneumonia ($45 ea.)

Name___________________________________( ) Flu Shot ($15 ea.) ( ) Pneumonia ($45 ea.)

Completed by:_____________________________________ ____________________________________

Print Name of Authorized Person Signature of Authorized Person