Vaccination Status Form

Use this form to upload a photo of your completed COVID-19 vaccination card (1 dose for Johnson/Johnson and 2 doses for Moderna or Pfizer).

Name Name First Last
Email
Please select your class status

Please select your class status Undergraduate Student Graduate Student Running Start Student Other: Non-Matriculated/Adult Learner/Student Auditing Class
I am a:

I am a: New Student (First year/transfer) Returning Student
Are you a student athlete

Are you a student athlete Yes No
Please select your sport(s):

Please select your sport(s): Women's Swimming Men's Swimming Women's Basketball Men's Basketball Football Volleyball Women's Soccer Men's Soccer Baseball Women's Tennis Men's Tennis Lacrosse Softball Women's Golf Men's Golf Women's Cross Country/Track Women's Track Only Men's Cross Country/Track Men's Track Only Cheerleading
Select one:

Select one: I am fully vaccinated for COVID-19 I do not intend on receiving the COVID-19 vaccination I am fully Vaccinated and boosted for COVID-19

Students who are not vaccinated but intend to become vaccinated should return to this page to submit a new form and upload their card once completed.
Date of 2nd (or final dose if J&J) dose of Vaccination: Date of 2nd (or final dose if J&J) dose of Vaccination: / MM / DD YYYY
Upload your vaccination card here:

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