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Proof of Covid-19 Vaccination
Please verify reCaptcha before submitting the form.
Temple Micah has decided the COVID-19 vaccine will be
mandatory
for all eligible persons (ages 5 and up) entering the building.
If you have been vaccinated, please upload a photo of your completed card below. If you have not yet been vaccinated, please do so as soon as possible in order to enter the temple building. If you require a medical exemption, please complete the form below and the office will contact you for further information.
*
First Name
*
Last Name
*
Please indicate your current Covid-19 vaccination status:
Please select one
I am fully vaccinated
I have a medical exemption and cannot receive the vaccine
I am only uploading vaccination cards for Machon students
Please provide the best phone number to contact you during business hours:
A Temple Micah staff member will contact you within 1-3 business days.
*
First Dose
Second Dose
Booster 1
Booster 2
*
Please upload a photo of your vaccination card below:
You can upload a maximum of 2 files.
Would you like to upload additional vaccination cards for your household?
Please Select One
Add Another Person
Add Machon Micah Students
*
First Name
*
Last Name
First Dose
Second Dose
Booster 1
Booster 2
*
Please upload a photo of your vaccination card below:
You can upload a maximum of 2 files.
Would you like to upload vaccine cards for Machon students?
No
Yes
How many vaccine cards are you uploading?
1
2
3
4
*
Please upload photos of your child's vaccination cards below:
*
Child's Full Name:
*
Child's Grade:
Please Select One
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
First Dose
Second Dose
*
Please upload photos of your child's vaccination cards below:
*
Child's Full Name:
*
Child's Grade:
Please Select One
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
First Dose
Second Dose
*
Please upload photos of your child's vaccination cards below:
*
Child's Full Name:
*
Child's Grade:
Please Select One
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
First Dose
Second Dose
*
Please upload photos of your child's vaccination cards below:
*
Child's Full Name:
*
Child's Grade:
Please Select One
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
First Dose
Second Dose
Fri, April 26 2024 18 Nisan 5784