Student COVID-19 Vaccination Status Form

Student COVID-19 Vaccination Status Form
To keep school safety, we are encouraging schools and families to verify students’ COVID-19 vaccination status for the 2021-22 school year.
Although the COVID-19 vaccine is not required to attend school right now, the information you provide will help our district be prepared to respond effectively when contact tracing is needed.
Acceptable forms of vaccine documentation:
1. Photo or copy of official vaccination card
2. Documentation from a health care provider (doctor, clinic, etc.)
3. Print out from State Vaccination Record System
All options must show name of person receiving the vaccination and include vaccination dates and vaccine type.
Student Name
First NameLast Name
Student ID
Number
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student Age
Parent/Guardian Name
First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student's Vaccination Status
Vaccination Details
Upload documentation of vaccination
Cancelof
Additional Notes (Optional)
Signature
Clear
Should be Empty: