2021-22 COVID-19 Volunteer Vaccination Clearance Form
All LPS volunteers must show proof of COVID-19 full vaccination for the 2021-21 school year and follow all other LPS safety protocols when volunteering in LPS school and central office buildings. Volunteers may not begin their assignment until they have been cleared by the school nurse and completed their CORI check with LPS Human Resources.  

To obtain clearance from the school nurse: Volunteers must complete this form and bring a:
(1) Photocopy of their CDC vaccination card (both the front and the back of the card)
(2) Photocopy of a government issued photo ID (e.g.  Passports, or Passport cards, Driver's licenses, or state ID cards)

Photocopies should be stored in a sealed envelope with the volunteer's name on it and delivered to the school’s main/front office. Any records received will be stored securely by the school nurse, who determines whether a volunteer is cleared for their assignment. Volunteers should NOT send digital copies via email or other means to any LPS staff members.

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Volunteer Last Name
Volunteer First Name
Volunteer Date of Birth
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Where are you volunteering? Check all that apply.
Vaccine Administered
Date of 1st vaccine
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DD
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YYYY
Date of 2nd vaccine (if applicable)
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DD
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YYYY
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