COVID-19 Vaccine Record

COVID-19 Vaccine Record

Complete the form below when you receive your COVID-19 immunization. Records will be kept on file with the Heath and Wellness Coordinator.
Name*

First NameLast Name
Your Relationship to the AAC*
Date of first immunization

MonthDayYear
Date
Date of second immunization

MonthDayYear
Date
Date of booster

MonthDayYear
Date
Copy of immunization record

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Attach a photo of your immunization record. Cancelof
All information entered is confidential.

Students, Faculty, and Staff are required to consent to and cooperate with the AAC Success and Wellness Plan and agree to protocols communicated. To find a copy of our COVID-19 Success and Wellness Plan, visit www.artacademy.edu/covid19
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