COVID-19 Vaccination Documentation
Please complete this form to document your son's COVID-19 vaccination. For your security, this form is encrypted.
Student First Name
*
Student Last Name
*
Student Grade
*
9
10
11
12
Parent/Guardian Name
*
First Name
Last Name
Parent Email
*
example@example.com
Type of COVID-19 Vaccination
*
Johnson & Johnson
Moderna
Pfizer
First Vaccination Date
*
-
Month
-
Day
Year
First Vaccination Lot Number
*
First Vaccination Lot Number
Second Vaccination Date
*
-
Month
-
Day
Year
Second Vaccination Lot Number
*
Second Vaccination Lot Number
Has your son received a COVID-19 booster vaccine yet?
*
Yes
No
Type of COVID-19 Booster
Johnson & Johnson
Moderna
Pfizer
Booster Vaccination Date
-
Month
-
Day
Year
Booster Vaccination Lot Number
Upload a copy of your son's vaccination card.
*
Browse Files
Please include an image of the full card.
Cancel
of
I verify that this card is authentic and was administered by a medical professional.
*
Submit
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