Chicago Hyde Park Village COVID-19 & Flu Vaccination Record

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The safety of our community members is of utmost importance. Chicago Hyde Park Village (CHPV) strongly encourages all persons attending in-person events to be current with their COVID-19 and flu vaccinations according to CDC guidelines.

Please complete this form EACH TIME YOU RECEIVE A COVID-19 VACCINATION or FLU VACCINATION and you anticipate attending CHPV in-person activities, including volunteering and event facilitation.

QUESTIONS?
Please email info@chpv.org or call Lucas Livingston, Executive Director, at ‪(773) 234-6428‬.

CDC Resources:

What is your affiliation with CHPV? *

Member

Volunteer

Non-member

Contractor/Employee

Other:

Required

First Name *

Last Name *

Provide the date of your most recent Covid-19 vaccination *

YYYY

Provide the date of your most recent flu vaccination

YYYY

This information you provide here is accessible to CHPV administrators only.

Do you consent to Chicago Hyde Park Village keeping a record of the information you provide in this form? *

Yes

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