VACCINATION FORM – Illuminate Arts Festival

Legal Name (as shown on legal ID and vaccination record) *

Name in Use/Chosen Name

Do you confirm you have received two doses of a government recognized COVID-19 vaccine? *

YesNo

Have you received a Booster dose of COVID-19 vaccine? *YES, I have already received a BoosterNO, but I am scheduled to receive a Booster before March 12, 2022NO. On March 12th, LESS than 5 months will have passed since my last dose.NO. On March 12th, MORE than 5 months will have passed since my last dose and I do not plan to get a Booster before March 12, 2022.

Upload photo of scan of government-issued ID (e.g. driver's license, Medicare card, birth certificate, other government ID, etc) *

No file chosen

Please upload a photo, scan, or screen shot of government-accepted proof of vaccination that clearly shows your name (e.g. MyHealthNB Screen Shot, Immunization Record, Vaccination Certificate from other jurisdiction, etc) *

No file chosen