Vaccine Status

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* First Name of Person Submitting this form

* Last Name of Person Submitting this form

* 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.

* Adult 1 First Name

* Adult 1 Last Name

* Is Adult 1 fully vaccinated?

* Date of Final Vaccine

* Upload Your Vaccine Card

Adult 2 First Name

Adult 2 Last Name

Is Adult 2 fully vaccinated?

Date of Final Vaccine

Upload Your Vaccine Card

Child 1 First Name

Child 1 Last Name

Is Child 1 fully vaccinated?

Date of Final Vaccine

Upload Your Vaccine Card

Child 2 First Name

Child 2 Last Name

Is Child 2 fully vaccinated?

Date of Final Vaccine

Upload Your Vaccine Card

Child 3 First Name

Child 3 Last Name

Is Child 3 fully vaccinated?

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

Sat, July 27 2024 21 Tammuz 5784