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* 1. I authorize and consent to the sharing of this information with the Connecticut Sun.

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* 2. First Name:

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* 3. Last Name:

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* 4. Date of Birth

Date

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* 5. Email:

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* 6. Have you been vaccinated for COVID-19?

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* 7. What type of COVID-19 vaccination did you receive?

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* 8. What was the date of your first dose?

Date

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* 9. What was the date of your second dose (if applicable)?

Date

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* 10. Please attach documentation of vaccination (e.g., photo of vaccine card, PDF of clinic record)

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