CHAMLIAN ARMENIAN SCHOOL

MyChamlian

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Vaccination Information Form

Please complete the form below. Required fields marked with an asterisk *

Name of Student*

Answer required for "Name of Student"

Student Grade*

Answer required for "Student Grade"

Name of Parent/Guardian*

Answer required for "Name of Parent/Guardian"

Date of First Vaccine*

Answer required for "Date of First Vaccine"

Manufacturer - First Vaccine*

Answer required for "Manufacturer - First Vaccine"

Pfizer

Moderna

Johnson & Johnson

Other:

Date of Second Vaccine

Answer required for "Date of Second Vaccine"

Manufacturer - Second Vaccine

Answer required for "Manufacturer - Second Vaccine"

Pfizer

Moderna

Johnson & Johnson

Other:

COVID-19 Vaccination Record Card*

Answer required for "COVID-19 Vaccination Record Card"

Choose a file or drag it here.

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"