Vaccine Verification Form

Covid-19 Vaccine Verification Form
You must upload a copy of your vaccine card below. You are not considered fully vaccinated until two weeks after your last vaccine.
Participant Name*
Birth Date*
MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email*
Parent/Guardian Name*
Primary Phone*
Date of First Vaccine
MM slash DD slash YYYY
Date of Second Vaccine (if applicable)
MM slash DD slash YYYY
Date of Booster Vaccine (if applicable)
MM slash DD slash YYYY
Date of Second Booster Vaccine (if applicable)
MM slash DD slash YYYY
Upload Files
Drop files here or

Max. file size: 64 MB.
Signature*

By typing your name in the field above and clicking submit, you agree that the above information has been completed to the best of your knowledge.

Contact Us

Please contact Ted Adatto, Superintendent of Recreation, at 630-681-0962 ext570 or teda@wdsra.com.