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Youth Vaccination Form
Please fill in your child's vaccination information below. The CDC considers someone to be fully vaccinated two weeks after the second dose of the Pfizer vaccine.
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* Indicates required question
Student Name
*
Your answer
Parent Name
*
Your answer
Date of your child's second dose of COVID vaccine:
*
MM
/
DD
/
YYYY
Date your child will be considered to be fully vaccinated (two weeks after the above date):
*
MM
/
DD
/
YYYY
Youth only: Have you received a COVID booster shot?
Yes
No
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