Fall 2020 Flu Vaccine Attestation Form - Student
By submitting this attestation I certify that I received my flu vaccine at a doctor's office, a pharmacy, or at a Stonehill College flu vaccine clinic. If I attended the Stonehill College flu vaccine clinic, CVS will provide this documentation to Stonehill Health Services directly. Please upload flu vaccine documentation if received off campus. If I did not receive a flu vaccine I've indicated it's because of a religious or medical exemption and I have uploaded the required documentation. I will notify Stonehill College Health Services at 508-565-1307 should I have any questions.
Name
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First Name
Last Name
Email
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example@example.com
I received a flu vaccine:
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At a Stonehill College flu clinic
At a doctor's office
At a pharmacy
Not applicable due to religious or medical exemption indicated below
I did not receive a flu vaccine due to the following exemption:
Due to religious exemption
Due to medical exemption
Please upload documentation
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Affirmation:
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By checking this box you are affirming that you received the "Fall 2020 Flu Vaccine or you are exempt due to a religious or medical exemption."
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