COVID-19 Information and Vaccination Form

Welcome

Welcome

* First Name

* Last Name

* Email

In order to attend in-person Suburban Temple - Kol Ami programming, proof of COVID-19 vaccination is required for ages 5+. There will be a grace period of 60 days from either a birthday making one eligible to receive your vaccine. It is our belief that vaccinations, including all eligible boosters, are a critical tool in the fight against COVID-19 and we encourage all to be "up to date" on vaccinations.

If your proof of vaccination is not submitted before coming to Temple, you will be required to show proof upon arrival.

People are considered fully vaccinated: 2 weeks after their second dose in a 2-dose series, like the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, like Johnson & Johnson’s vaccine.

A person is considered "up to date" if they have received a booster. At this time, the CDC recommends that all adults (ages 18+) receive a mRNA booster (Pfizer or Moderna). Children ages 12+ who received the Pfizer vaccine are eligible to receive the Pfilzer booster. (*as of 1/12/2022 per CDC.gov)

If you have not/are unable to receive a booster and wish to attend in person programming, please contact Brett Shankman.

We are following CDC guidance on masking. While Cuyahoga County is a "low" transmission county or "green", masks will be optional in the building. Thank you.

* Adult 1 First Name

* Adult 1 Last Name

* Vaccination Status (choose only 1)

Adult 1 is fully vaccinatedAdult 1 is up to date

* Date of Final Vaccine

Upload Adult 1's Vaccine Card

Adult 2 First Name

Adult 2 Last Name

Vaccination Status (choose only 1)

Adult 2 is fully vaccinatedAdult 2 is up to date

Date of Final Vaccine

Upload Adult 2's Vaccine Card

Child 1 First Name

Child 1 Last Name

Vaccination Status (choose only 1)

Child 1 is fully vaccinatedChild 1 is up to date

Date of final vaccination

Upload Child 1's vaccination card

Child 2 First Name

Child 2 Last Name

Vaccination Status (choose only 1)

Child 2 is fully vaccinatedChild 2 is up to date

Date of final vaccination

Upload Child 2's vaccination card

Please note any other members of your family who have been fully vaccinated and/or are up to date

Upload any additional vaccination cards

Mon, February 6 2023 15 Sh'vat 5783