2023 Health Clearance Form

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If you are to participate in the IEFLP Leadership conference, you and your parents/guardians (if under 18) must complete this health clearance form. You cannot attend the conference if this information is not submitted. 

Staff: You must complete and submit this form by February 1st, including vaccination records.

Delegates: You must complete and submit this form by March 15th, including vaccination records.

**PLEASE MAKE SURE YOU SUBMIT A COPY BELOW OF ALL VACCINATION RECORDS, INCLUDING COVID VACCINATION CARDS.**







Birthdate



Health Insurance Information






**PLEASE MAKE SURE YOU SUBMIT A COPY BELOW OF ALL VACCINATION RECORDS, INCLUDING COVID VACCINATION CARDS.**
Measles, Mumps, and Rubella (MMR)
Date of 1st dose:



Date of 2nd dose:



Tetanus/TDAP
Date of last dose:



COVID-19 Vaccine (ONLY 2 DOSES REQUIRED, 3RD OPTIONAL)
Date of 1st dose:



Date of 2nd dose:



Date of 3rd dose:



Date of additional dose (i.e. 
boosters):



COVID-19 Vaccine
Date of 1st dose:




Date of 2nd dose:




Date of additional dose (i.e. booster):










Consent Forms

Please read the following forms and provide signatures below: 

Agreement and Medical Release Form

My signature below indicates that I have read and consent to all documents above. I affirm that the information provided by me/us in this health clearance form is correct, and I consent to its release to IEFLP. 



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