Immunization Information Form

All requested information is mandatory to on-board as a volunteer. Flu is required seasonally.

You will also be required to upload the documentation of your immunizations for final verification.

**If you do not have a copy of your immunization document from your physician, please click here to download a form for your doctor to complete. After your doctor has completed the form you may use the information to complete the immunization dates on this page then upload the form (below) for final verification.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Do Not list any dates below that cannot be verified on the accompanying copy of your immunization record. All required dates MUST have supporting documentation. If you do not have the documentation you must wait to complete this form until you have obtained the required information from your doctor.

* MMR Second vaccine date or date of titer

* Varicella vaccine date, or date of disease, or date of titer

* PPD test date (TB test) must be valid within past 12 months

Results

* Date of most recent Flu vaccine

Vaccine given where?

Flu Vaccine  Lot#                 (use  n/a  if   Lot#   is not listed)

If you have had a COVID vaccine or Booster AFTER APRIL 28, 2023, please list the date of your vaccine below.

Date of COVID Vaccine/Booster

* Upload copy of Immunization Document from Physician

Upload additional Immunization Documentation if needed