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Northbrook School District 27 is verifying COVID-19 vaccination status for eligible students on a voluntary basis. This helps expedite our contact tracing process. Please complete this form for every student in your household that has received a complete series of the COVID-19 vaccine. Thank you!

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* 1. Student First Name

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* 2. Student Last Name

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* 3. Name of Parent Completing This Form

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* 4. Email of Parent Completing This Form

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* 5. Preferred Contact Number of Parent Completing this Form

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* 6. Which vaccine did the student receive?

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* 7. Date of first dose

Date

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* 8. Date of second dose

Date

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* 9. Date of Booster shot.

Date

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* 10. Please upload a photo or scanned copy of the student's vaccine card.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 11. Select Current School

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* 12. Student Grade Level

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