COVID Vaccination Verification Form

First Name

Last Name

Vaccination Status

Vaccine Type

If other please list detail here:

Intent to vaccinate?

Vaccination Date #1

Please list the date that you received your first dose of the vaccine?

Vaccination Date #2

Please list the date that you received your second dose of the vaccine?

Please upload a copy of your vaccination card or printout that indicates what COVID-19 vaccine you received, the date(s) you received it, and where you received it?

Have you received a booster shot?

Booster Type

If other please list detail here:

Booster Date

Please list the date that you received your first dose of the vaccine?

Contact Information