Silver Music: Covid-19 - 1 Shot Received (Partially Vaccinated) form

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All eligible students (12 years +) and accompanying adults (who might attend programs along with a student) must receive one dose of the COVID -19 vaccine by September 10, 2021, and the second dose by October 15, 2021. ("Accompanying adults" may include parents, caregivers, grandparents, etc). A form should be completed for each individual over age 12.

Please input information below including the date of the first shot and the scheduled date of the second shot. If the individual is fully vaccinated, complete our fully vaccinated link instead.

Thank you for your cooperation as we work to make our school as safe as possible this semester!

Name of Vaccinated Individual *

Email *

I am submitting this form for: *

a student (age 12+)

an accompanying adult

a teacher/staff member

If this form is being submitted for an accompanying adult, please write the name of the associated Silver Music student(s) below

Enter date shot 1 of Covid vaccine was received *

YYYY

When is shot 2 of the Covid vaccine scheduled? *

YYYY

Vaccine Manufacturer *

Moderna

Pfizer

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