Model Vaccination Form

"*" indicates required fields

Name*

First Middle Last

LCAD Email*

Enter Email Confirm Email

I am*

Explain*

Accommodation request for:*

Please download the following form HERE. Please submit completed form to covid@lcad.edu by January 14th 2022.

Please identify your sincerely held religious belief, practice, or observance that is the basis for your request for an Exception as a religious accommodation.*

Please briefly explain how your sincerely held religious belief, practice, or observance conflicts with the College’s COVID-19 vaccination requirement.*

Please provide any additional information that you think may be helpful in processing your religious accommodation request.*

This is the statement Positive Test

Please upload your positive COVID resultes here.*

Max. file size: 2 MB.

I do not plan on getting the vaccination or an exemption and understand I will not be able to come on campus for any reason. I have received information from LCAD about the COVID-19 vaccine. I understand that I may be at risk of acquiring COVID-19 infection and spreading it to others. I have been given the opportunity to be vaccinated with the COVID-19 vaccine.

Do you have a vaccination card or QR code?*

Vaccination Card

QR Code

If you would like to get a QR code of your COVID-19 vaccination record, go to: https://myvaccinerecord.cdph.ca.gov/

QR Code*

Max. file size: 2 MB.

Please upload an image of the (FRONT) of your vaccination card.*

Max. file size: 2 MB.

Please upload an image of the (BACK) of your vaccination card.*

Max. file size: 2 MB.

Product*

Date of 1st dose*

Lot/Batch*

Site/Location*

Date of 2nd dose*

Lot/Batch*

Site/Location*

Signature*