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Student COVID-19 Vaccination and Infection Status
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Student First Name
*
Your answer
Student Last Name
*
Your answer
Campus
*
Elementary
Middle
Vaccination Status
*
My child is vaccinated.
My child is not vaccinated.
If vaccinated, indicate date of last administration.
MM
/
DD
/
YYYY
If boosted, indicate date of booster.
MM
/
DD
/
YYYY
My child has tested positive for COVID-19 in the past 90 days.
*
Yes
No
If your child has tested positive in the past 30 days, indicate date of positive test.
MM
/
DD
/
YYYY
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