Scholar COVID-19 Vaccination Card

Please complete the form below and upload a copy of your COVID-19 vaccination card(s).

Student Name Student Name First Last
Student Grade Level
Please select your Vaccine Provider:
If you selected "other" above, please indicate the name of your Vaccine provider below.
What is the date of your first dose of COVID-19 Vaccination? What is the date of your first dose of COVID-19 Vaccination? / MM / DD YYYY
What is the date of your second dose of COVID-19 Vaccination? What is the date of your second dose of COVID-19 Vaccination? / MM / DD YYYY
What is the date of your first COVID-19 booster shot? What is the date of your first COVID-19 booster shot? / MM / DD YYYY
What is the date of your second COVID-19 booster shot? What is the date of your second COVID-19 booster shot? / MM / DD YYYY
Upload a copy of your COVID-19 vaccination card(s).

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