Special Olympics Wisconsin Vaccine Verification

Special Olympics Wisconsin Vaccine Verification

Last Name*

First Name*

Email Address*

Local Program

Select

Participant Type*

Select

Date of Birth*

I certify that I am fully vaccinated against COVID-19.*

Fully vaccinated is defined as two weeks after the last dose.

Select

Name of Vaccine*

Select

Vaccination Date*

If you received a vaccine with a two-dose series (Moderna or Pfizer/BionTech), please list the date of your second dose. If you received the Johnson & Johnson/Janssen vaccine, please list the date of your single dose.

Have you received a booster shot for COVID-19?*

Select

Name of Vaccine of Booster Dose*

Select or enter value

Date of Booster Dose*

Please upload a copy of your completed COVID-19 vaccination record.*

Please upload PDF or JPEG file only.

Drag and drop files here or

If you would like to receive a copy of your submission via email, please check the box below.

Send me a copy of my responses

Privacy Notice|Report Abuse