Vax | MakeHaven

Vax

This form certifies that you or the minor child you are signing for are considered fully vacciated by CDC definition:

2 weeks after your second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or
2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine

You must complete this form if you wish to be in MakeHaven while community transmission is at substantial or high levels according to CDC county levels.

PLEASE NOTE: Staff reserves the right to have you produce a record of your vaccination. We suggest taking a photo of the card to have available in your phone, or putting a photocopy in your wallet.

First Name *

Last Name *

Email *

Signing on behalf of *

Self

Minor Child

Children

Child #1

Child's First Name

Child's Last Name

Child #2

Child's First Name

Child's Last Name

Child #3

Child's First Name

Child's Last Name

Child #4

Child's First Name

Child's Last Name

Certify

I certify that I (or the minor child, as indicated) have been fully vaccinated (2 weeks after a second shot of a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine) as of today's date.

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