Student Vaccination Form

"*" indicates required fields

Name*

First Middle Last

LCAD Email*

Enter Email Confirm Email

Student ID #*

I am*

Explain*

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 Upload*

Max. file size: 2 MB.

I understand that by selecting this option I am unable to be physically present on the LCAD campus for any reason.

Product*

If you were fully vaccinated outside the U.S., the vaccine you received may not appear in the options below. In that case, please select any of the available options (it doesn't matter which) and then be sure to indicate which vaccine you actually received in the comment boxes below. If you received one vaccine outside of the U.S. and the second vaccine within the U.S., please select the brand name of the second vaccine you received.

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.

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.

Date of 1st dose*

Lot/Batch*

Site/Location*

Date of 2nd dose*

Lot/Batch*

Site/Location*

Signature*