WCS STUDENT VACCINATION ATTESTATION FORM
Parents / Caregivers: We are requesting that you voluntarily share the vaccination status of your child. At this time, we will use this information in the event of contact tracing to determine whether or not your child must quarantine if they are identified as a close contact. Individuals who are fully vaccinated are not required to quarantine in the event they are exposed to a positive case. In the future, it may be used to calculate the vaccination rate for our school. If you have more than one child in our school who is eligible, please fill the form out separately for each child.

If you decline to provide this information for your eligible student(s), they will be considered to be not vaccinated, and therefore would need to test/quarantine in the event they are identified as a contact.
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Champlain Valley School District
Student First Name *
Student Last Name *
Student Date of Birth *
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/
DD
/
YYYY
Student Grade *
House at WCS *
Student Vaccine Information
Date of First Dose
if applicable
MM
/
DD
/
YYYY
Type of Vaccine
first dose
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Date of Second Dose
if applicable
MM
/
DD
/
YYYY
Type of Vaccine
second dose
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By clicking YES below, I attest that the information I have provided is true and correct.
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Parent/Caregiver First Name *
Parent/Caregiver Last Name *
Parent/Caregiver Email Address
Parent/Caregiver Phone Number
Please indicate how you will provide proof of vaccination
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