Flu & COVID Vaccines
Last Flu Vaccine Date : ( attach verification as appropriate )
Student Name ________________________________________________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip ________________
COVID Vaccinations : ( attach verification as appropriate ) Date of 1st Dose __________________ Type / Maker _________________________________ Date of 2nd Dose _________________ Type / Maker _________________________________ Date of Booster ___________________ Type / Maker _________________________________
Physician _____________________________________ Phone __________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip ________________
Physicians Signature __________________________________________________________
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