COVID Vaccination (Non-CDC issued) Form
This form should be completed by any RubyConf attendee who DOES NOT have a CDC-issued vaccination card, have a verified Clear Health Pass vaccination (Johnson & Johnson's Janssen, Pfizer - BioNTech, and Moderna), or who identifies as trans/non-binary. Upon arrival to the 2021 RubyConf, attendees MUST SHOW their vaccination cards during conference check-in. A copy of this form will be emailed to you as confirmation.
Clear Health Pass vaccinations should confirm their vaccination record using the Clear Health app.
If you have additional questions regarding the RubyConf vaccination requirements or if there are areas not covered in the form below, please email us at
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Are you fully vaccinated from COVID-19?
I have mixed vaccinations
Which COVID Vaccine did you receive? (If mixed, please list all names)
Date of First Shot
Date of Second Shot
Additional Shot Date(s)
I understand that a COVID vaccination is required to attend the 2021 RubyConf. I agree to show my COVID vaccination card upon checking in to the RubyConf.
I confirm my understanding of the COVID-19 policy and showing a physical copy of my COVID Vaccination card.
A copy of your responses will be emailed to the address you provided.
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