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Covid Immunization Information
Please fill out this form and submit with appropriate documents.
Name
*
First Name
*
Last Name
*
I am
*
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New Student to Bethany College
Returning Student to Bethany College
Session/Year
*
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Spring, 2024
Fall, 2024
Email
*
Bethany ID Number
*
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*
I have gotten the COVID-19 immunization vaccine - and I am uploading my vaccincation card.
I do not intend to get the vaccine.
I have gotten the 1st shot of the COVID-19 vaccination, but will not have had the 2nd shot by the time I arrive on campus. I am uploading proof of my 1st shot and will provide final proof of my 2nd shot when available.
What type of vaccine did you receive?
Select One
Moderna
Pfizer
Johnson & Johnson
Please Select One
I have received the COVID-19 booster.
I have not received the COVID-19 booster.
If you received the booster shot and it was a different type than your original vaccine, what type was it?
Select One
Moderna
Pfizer
Johnson & Johnson
Upload COVID-19 Immunication Record with Booster
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