In an effort to maximize protection against serious disease, hospitalization and death, Beth Israel Center requires COVID-19 vaccination for all vaccine-eligible people -- including staff, program participants, students, visitors, service providers and others -- prior to entering the building.

Thank you for providing your vaccination verification.

INSTRUCTIONS:
At the TOP of this form, enter the name of the person whose vaccination status you are verifying on this form. You will see the name(s) of everyone in your household if you are logged into your ShulCloud account. Click Login at the top of the page if you do not see a box at the top of this form.

Below, please enter your name, whether you are completing this form for yourself or for someone else in your family.

WHEN YOU ENTER YOUR NAME BELOW, YOU ARE ATTESTING TO THE TRUTHFULNESS AND ACCURACY OF EVERYTHING ON THIS FORM.