VCFA Vaccination Status Survey
Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone Number
*
VCFA Affiliation
*
Please Select
Student
Faculty
Staff
Guest
Program / Residency / Event
*
Please Select
Postgraduate Writers’ Conference
Novel Retreat
Residency - Colorado College
Residency - Susquehanna University
Are you vaccinated for COVID-19?
*
Please Select
Yes, completed more than 2 weeks ago
Yes, still in process OR less than 2 weeks ago
No, and I would like to request an exemption from this vaccination
Please describe why would you like to be exempt from this vaccination requirement.
*
Have you had your booster shot?
*
Please Select
Yes, I have.
No, not eligible due to timing of my initial shot (or shots).
No, internationally located without access.
No, access issues in my state.
No, I am requesting exemption for this booster.
Please describe why would you like to be exempt from this booster requirement.
*
Please upload your COVID-19 vaccination card here:
*
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Examples: photo of physical card, screenshot of digital card
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