Name *

First Name

Last Name

Vaccination Status *

I affirm that I am vaccinated against COVID-19.

I have not been vaccinated.

If you have been vaccinated, please complete the fields below:

Please indicate type of vaccine:

Moderna

Pfizer

Johnson & Johnson

Other

Date of first vaccine

MM

DD

YYYY

Date of second vaccine, if applicable

MM

DD

YYYY

Date of booster, if applicable

MM

DD

YYYY

Additional vaccine, if applicable

MM

DD

YYYY