Proof of Covid-19 Vaccination

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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 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

Would you like to upload additional vaccination cards for your household?

* First Name

* Last Name

First Dose

Second Dose

Booster 1

Booster 2

Would you like to upload vaccine cards for Machon students?

NoYes

How many vaccine cards are you uploading?

* Child's Full Name:

* Child's Grade:

First Dose

Second Dose

* Child's Full Name:

* Child's Grade:

First Dose

Second Dose

* Child's Full Name:

* Child's Grade:

First Dose

Second Dose

* Child's Full Name:

* Child's Grade:

First Dose

Second Dose

Fri, September 19 2025 26 Elul 5785