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Vaccine Status
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First Name of Person Submitting this form
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Last Name of Person Submitting this form
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Email
Congregation Beth Shalom requires all individuals age 5 and over entering the building to be vaccinated for COVID and to provide proof of vaccination.
This mandate is for anyone who is eligible to be vaccinated, and then when eligible, to obtain a booster.
Once your COVID proof of vaccination card has been uploaded, we will have your name at the front entrance or in the synagogue office to confirm your proof of vaccination.
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Adult 1 First Name
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Adult 1 Last Name
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Is Adult 1 fully vaccinated?
Please Select One
Yes
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Date of Final Vaccine
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Upload Your Vaccine Card
Adult 2 First Name
Adult 2 Last Name
Is Adult 2 fully vaccinated?
Please Select One
Yes
Date of Final Vaccine
Upload Your Vaccine Card
Child 1 First Name
Child 1 Last Name
Is Child 1 fully vaccinated?
Please Select One
Yes
Date of Final Vaccine
Upload Your Vaccine Card
Child 2 First Name
Child 2 Last Name
Is Child 2 fully vaccinated?
Please Select One
Yes
Date of Final Vaccine
Upload Your Vaccine Card
Child 3 First Name
Child 3 Last Name
Is Child 3 fully vaccinated?
Please Select One
Yes
Date of Final Vaccine
Upload Your Vaccine Card
Please note any other members of your family who have been fully vaccinated
Upload Your Vaccine Card
Tue, March 18 2025 18 Adar 5785
