Covid-19 Vaccination Attestation Form

All members of the Williams community, including non-matriculated students taking classes at the college, are required to be fully vaccinated and boosted, if eligible.

Please select the statement below that accurately describes your vaccination status: *

I am fully vaccinated. If eligible for a booster, I have received it.

I am either not fully vaccinated, or I am vaccinated and eligible for a booster, but have not yet received one.

Student First Name

Student Last Name

Student Email Address

I understand that I am required to provide accurate information about my vaccination status, and hereby affirm that I have completed this form truthfully.

Student Electronic Signature:

Date:

Are you currently younger than 18?

Yes

As you are younger than 18, a parent or guardian must complete the following:

I affirm that I am the custodial parent or legal guardian of the student identified above and that all information provided on this registration form is true and correct. I give my permission for my student to take the class listed below at Williams College and agree that my student must comply with the Williams College Code of Conduct as a condition of their attendance.

Parent/Guardian Electronic Signature:

Course Title

Date:

Parent Email Address

Covid-19 Vaccination Attestation Form

Post #13676

Admission

Student Financial Services

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