2021-22 Student Vaccination Survey

Consistent with recommendations from the CDC and the Westchester County Department of Health, the District is seeking your parntership to confirm the vaccination status of all students. Fully vaccinated students significantly reduce the risk of contracting or spreading COVID-19 and will avoid having to quarantine in the event of exposure. To avoid quarantining or the need to participate in COVID-19 testing, the District strongly recommends all eligible students get the COVID-19 vaccine.

This survey should be completed for all K-12 students. You will be prompted to complete this survey for each child attending Harrison schools.

Student Name *

First Name Last Name

Date of Birth *

Date

Student Cell Phone *

Please enter a valid phone number.

Student Email Address *

example@example.com

School

Harrison High School Louis M. Klein Middle School Harrison Ave Elementary School Parsons Memorial Elementary School Purchase Elementary School Samuel J. Preston Elementary School

Parent/Guardian Completing this Form *

First Name Last Name

Parent/Guardian Email Address *

example@example.com

Parent/Guardian Cell Phone *

Please enter a valid phone number.

Parent/Guardian Home Phone *

Please enter a valid phone number.

The CDC and the Westchester County Department of Health have identified certain sports that present a higher risk of COVID-19 exposure due to close proximity and increased exhalation. The CDC and WCDOH advise that students who participate in "high risk" sports (e.g., basketball, volleyball, cheerleading, wrestling) provide proof of COVID-19 vaccination. In order to participate in these "high risk" sports, the District requires students to provide proof of vaccination OR consent to COVID-19 testing.

Students who participate in athletics indoors will be required to wear a face covering, but face coverings are not required for outdoor activities.

Will your child be participating in a "high risk" sport (football, volleyball, cheerleading, wrestling)?

YES NO

High Risk Sports (check all that apply)

Basketball Cheerleading Volleyball Wrestling

Select one of the following: *

I am submitting proof that this child has completed TWO doses of the COVID-19 vaccination series I am submitting proof that this child has completed the FIRST dose of the COVID-19 vaccination series and is scheduled to receive the second dose My child is not vaccinated and will participate in COVID-19 testing in order to participate in "high risk" athletics

Select one of the following: *

I am submitting proof that this child has completed TWO doses of the COVID-19 vaccination series I am submitting proof that this child has completed the FIRST dose of the COVID-19 vaccination series and is scheduled to receive the second dose My child is not vaccinated and I will provide consent for my child to be tested weekly

Upload proof that this child has completed TWO doses of the COVID-19 vaccination (e.g., COVID-19 vaccination card or Excelsior Pass screen shot) *

Upload proof that this child has completed the FIRST dose of the COVID-19 vaccination and is scheduled to receive the second dose (e.g., COVID-19 vaccination card or Excelsior Pass screen shot) *

Parent/Student Agreement to the Conditions Above *

Yes, I agree

Harrison Central School District