Vaccination Declaration
The person named below should only mark vaccinated if they are fully vaccinated against COVID-19. This includes all necessary shots plus the CDC recommended waiting period. All members accept the inherent risk of close contacts, and they agree that they will not hold PCS liable.
Name
*
First Name
Last Name
Member or Guest
*
Member
Guest
Member Number (If Known)
Are you fully vaccinated?
*
yes
no
Date of Full Effectiveness
*
-
Month
-
Day
Year
Date
Upload Vaccination Card
*
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If Under 18, Parent Signature
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Date of Birth
-
Month
-
Day
Year
Date
Race/Ethnicity
Black/African-American
White/Caucasian
Middle Eastern/Arab
Asian/Pacific-Islander
Hispanic/Latinx
American Indian/Alaskan Native
Prefer not to say
Gender
Male
Female
Non-Binary
Prefer not to say
Do you meet child care subsidy income requirements? (Family of 1 < $40,000, 2 < $53,000, 3 < $65,000, 4 < $77,000, 5 < $89,000, 6 < $102,000, 7 < $104,000, 8 < $106,000, 9 < $108,000, 10 < $110,000) *
Yes
No
Prefer not to say
What languages do you speak?
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