Please submit COVID-19 Vaccine Documentation
Pre-filled Information
Student/Employee ID number
*
(this is pre-filled and you cannot change it)
Student/Employee name
*
First Name
Last Name
Please fill in the information below
Documentation Requirements
Please ensure the documentation you submit is for a COVID-19 vaccine. Do not submit COVID tests here. Please ensure it has the Date of the Shot and Your/Your Child's Name. The name should match the name above.
Vaccine Shot date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date shot was administered
Is this...
*
First shot
Second shot
Did you schedule your second shot?
*
Yes
No
What is/was the expected date of your second shot?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
The Brand of your shot was...
*
Pfizer
Moderna
Unsure
Other
Please attach a clear PDF or image of the COVID Vaccine shot documentation:
*
Browse Files
Cancel
of
Please click the box to acknowledge that the documentation includes the name of the person who received the vaccine and the date of administration.
*
I acknowledge
Submit
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