Volunteer Vaccination status form
AYSO Region 88 Glendale / Per L.A. County Public Health Order 08/30/2021
Volunteer Name
*
First Name
Last Name
Email
*
example@example.com
Volunteer Role
(eg. Head Coach, Referee, etc.)
Vaccination Status
*
Fully Vaccinated
Unvaccinated and will test weekly
Tested positive more than 10 days ago, and less than 90 days ago (COVID immunity)
None of the above, I will contact you with my concern or provide a comment below
Dose 1 administered
-
Month
-
Day
Year
Date
Dose 2 administered
-
Month
-
Day
Year
Date
Dose 3 administered
-
Month
-
Day
Year
Date
Proof of Vaccination
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Submission of Vaccination Proof
I wish to submit Vaccination proof in person
Comment
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