COVID-19 Vaccine Authorization Form

COVID-19 Vaccine Authorization Form
This form is for the employees of the organization who wants to receive the COVID-19 Vaccine.
Kindly make sure that all of your employees are aware of the vaccination process and they understand the benefits of having the vaccine.
Please have each employee sign a separate form indicating that they are interested in receiving the vaccine.
Inform them that only the employee is covered in terms of receiving the vaccine via this form and not his/her family members or relatives. Non-employee have a separate form that should be provided by the local government.
Today's Date
MonthDayYear
Date
Organization/Institute Name
Organization Type (Hospital, Long-term facility, etc.)
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Primary Contact Person
First NameLast Name
Primary Contact Phone Number
Please enter a valid phone number.
Primary Contact Email Address
example@example.com
Secondary Contact Person
First NameLast Name
Secondary Contact Phone Number
Please enter a valid phone number.
Secondary Contact Email Address
example@example.com
List the employees who are interested in receiving the COVID-19 vaccine
Name of Authorize Person who will sign this form
First NameLast Name
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty: