Student Vaccination Status

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Please complete the following form by December 17. You must complete this form AND email proof of your child's vaccination status to nurse@mfriends.org.

Name of student: *

Grade of student for the 2021-22 school year: *

Please select the statement below that accurately describes your student’s vaccination status: *

My student is FULLY vaccinated (email proof to nurse@mfriends.org)

My student is NOT fully vaccinated, but received ONE DOSE of a two-dose vaccine. Please provide date of the 2nd dose on the next screen.

My student is NOT VACCINATED.

I do not wish to disclose my student's vaccination status and understand that the school will consider my child to be unvaccinated.

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