STEP 1: HIPAA Authorization for the Disclosure of Health Information

By signing this Authorization, I acknowledge that I have read and understand this Authorization. Further, I authorize the disclosure of the information set forth herein in accordance with the terms of this Authorization.

Use your mouse or finger to draw your signature above

STEP 2: Registration & COVID-19 Vaccine Record Upload

Type of Vaccine

Each attendee must create their own registration to receive an email stating the submission has been verified.

Name*
Address
Date of Birth (mm-dd-yyyy)*

We will contact you via email if we have any questions or concerns about your submission.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

STEP 3: IHP Consent, Terms , and Conditions

By signing below, I hereby acknowledge and agree that I have read the Agreement and agree to all terms and conditions contained therein.

Use your mouse or finger to draw your signature above
Date Signed*

Confirmation

Attendee has submitted a valid vaccination record.*
Date