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Date*

Vaccination Record Upload

Are you uploading a vaccination card, negative covid test result, or proof of recovery within the last 90 days?*
Type of Vaccine*
Name*
Date of Birth (mm-dd-yyyy)*
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File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
Specimen Collection Date/Time*
:  
Test Result Date/Time*
:  

CDC COVID-19 Vaccination Record Card Warning 

CDC COVID-19 Vaccination Record Cards are official federal documents issued by the Centers for Disease Control. It is ILLEGAL to upload, provide, present, utter, or otherwise use a falsified CDC COVID-19 Vaccination Record Card. A CDC COVID-19 Vaccination Record Card is falsified: If the person uploading, providing, presenting, uttering or otherwise using the card did not receive the vaccination(s) as stated on the card; or if the person uploading, providing, presenting, uttering, or otherwise using the card, is an adult who is uploading, providing, presenting, uttering, or otherwise using the card on behalf of a minor, and the minor has not received the vaccination(s) as stated on the card. 

  1. I understand that it is illegal to upload, provide, present, utter, or otherwise use in any way a falsified CDC COVID-19 Vaccination Record Card. I understand that violators may be prosecuted for any or all of the following offenses: 
    1. I understand that violators may be subject to federal prosecution under 18 U.S. Code § 1017 - Government Seals Wrongfully Used and Instruments Wrongfully Sealed, and upon conviction be sentenced to serve up to 5 years in prison, and to pay up to a $250,000 fine; 
    2. I understand that violators may be subject to state prosecution under federal or state statutes and upon conviction may be sentenced to serve time in jail, and pay a fine as indicated by the state of residence. 

I declare under penalty of law that I have received, read, and understood the above Falsified CDC COVID-19 Vaccination Record Card Warning. 

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Confirmation

Attendee has submitted a valid Vaccination Record*