Covid Vaccination Information Form
Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Please indicate if you are a student or an employee
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Student
Employee
Please indicate whether you are submitting information about your vaccine , booster, or request for exemption.
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Vaccine
Booster
Request for Medical or Religious Exemption
Please upload a photo or a scanned and saved PDF of your covid vaccination card here. Please be sure the photo is in focus, close up, and that all of the information is showing. Thank you.
*
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