AMGA Small Event Vaccine Attestation Statement

As part of AMGA’s commitment to the health and safety of our event attendees and supporters, vaccination is required to attend this event.  You must be fully vaccinated* according to CDC guidelines and provide proof of your vaccination via attestation.  Failure to attest before arrival onsite will require participants to display proof of vaccination upon check-in at AMGA’s registration desk -  proof can be original vaccination card, copy of front/back of card, photo of front/back of card and/or any other electronic or app based vaccine verification.  Failure to provide verification of vaccination will impact your ability to enter the event space. 
*CDC has approved or authorized three vaccines to prevent COVID-19. They are Pfizer-BioNTech, Moderna and Johnson &Johnson’s Janssen. A person is fully vaccinated 2 weeks after the 2nd dose of Pfizer and Moderna vaccines. A person is fully vaccinated 2 weeks after 1st dose of J&J’s Janssen. 

Please complete this form to let us know whether and when you have received the vaccine. Information provided within this form will be kept confidential. We are asking for dates of the vaccination to help determine when each participant is considered fully vaccinated. When completing this form, do not provide any medical information, or any other information related to why you may not have received a COVID-19 vaccine. Simply fill in your name, fill in your response, and select the events you're registered to attend.  If your situation changes in the future, please provide an updated attestation at that time.

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* 1. Name

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* 2. Email

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* 3. I received the complete series of the COVID-19 vaccine as of date indicated (enter date).

Date

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* 4. Will you be fully vaccinated with COVID-19 vaccine at the time of your scheduled AMGA event attendance?  (please do not provide any additional information).

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* 5. Please select the AMGA event you will be attending:

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* 6. Enter initials to sign attestation

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