Covid-19 Vaccination Questionnaire & Affidavit
The CDC has lifted the mask requirement for those who are fully vaccinated against Covid-19.  Urban Yoga will now agree to allow students to remove masks during classes who fall into this category.  Please provide the following information to participate without a mask in Urban Yoga classes in the studio.
Have you been fully vaccinated against Covid-19. *
Required
Did you receive Pfizer, Moderna or Johnson & Johnson? *
Please provide the 2 dates of injection for Moderna / Pfizer or the date of the single dose of Johnson & Johnson. *
This form shall serve as my affidavit that I completed my COVID-19 vaccination. I will provide a copy/receipt/vaccine card from vaccine administrator if required. (Please do NOT include any personal medical information with this form). This COVID-19 Vaccination Form confirms that the individual named above received either both Moderna/Pfizer or single Johnson & Johnson COVID-19 vaccination at least 2 weeks prior to the date of attendance at Urban Yoga.  If you receive a vaccine that requires two shots, you will need to wait until you’ve received the second shot before you can submit this form. If you receive a COVID-19 vaccine that requires only one dose, then you can submit this form and copy/receipt/vaccination card after the one shot.  By electronically signing my name below I certify this information to be full and true.   *
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