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!

Question Title

* 1. Student First Name

Question Title

* 2. Student Last Name

Question Title

* 3. Name of Parent Completing This Form

Question Title

* 4. Email of Parent Completing This Form

Question Title

* 5. Preferred Contact Number of Parent Completing this Form

Question Title

* 6. Which vaccine did the student receive?

Question Title

* 7. Date of first dose

Date

Question Title

* 8. Date of second dose

Date

Question Title

* 9. 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
0 of 11 answered
 

T