7th Annual Pediatric Puzzles CME Conference: COVID-19 Vaccination Confirmation Form

All participants (registrants, exhibitors, and staff) must be fully vaccinated against COVID-19 (final shot at least 14 days prior to December 10, 2022). Please complete this form by Wednesday, December 7, 2022.

If you are unable to complete the form, please bring proof of vaccination (your vaccination card, or the QR code from California) to registration on Saturday, December 10. No one will be admitted to the conference without proof of vaccination.

Masks may be required depending on county regulations at the time of the event.

Please feel free to reach out to me if you have any questions or concerns: Yolanda Ruiz, Project Assistant, at info@aapca1.org

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* 1. Full Name

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* 2. Email Address

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* 3. Phone Number

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* 4. I am a...

Conference Registrant

Conference Exhibitor

Other (please specify)

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* 5. If Exhibitor, Please Indicate your Organization Below

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* 6. Please include an image of your COVID-19 vaccine card or your Digital Vaccine Record from California https://myvaccinerecord.cdph.ca.gov/ (or appropriate state).

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