COVID-19 Proof of Vaccination for Visitors

The proof of vaccination will not be stored once it is reviewed by Urban staff. We will record that you are fully vaccinated and are allowed to attend on-campus events without proof of a recent negative COVID-19 test.

Proof of COVID-19 vaccine options include your vaccine card image (jpg, png, etc), California Immunization Registry record (pdf), or your California Digital COVID-19 Vaccine Record screenshot/QR code image.

For questions or assistance, please contact Pandemic Coordinate Evie Hidysmith ('17) or Office & Logistics Manager Drea Scally.

Required

This form will be used to verify that Urban visitors are fully vaccinated prior to coming on campus. The proof of vaccination will be viewed by the school's Pandemic Coordinator Evie Hidysmith or Drea Scally, Office & Logistics Manager. All copies of vaccination proof will be deleted and the only information that will be stored are the names of those who are fully vaccinated and allowed to come on campus.
Namerequired
First Name
Last Name
Please let us know which of these roles applies to you (you may choose more than one):required
Attach up to 1 file at a time. File size may not exceed 20MB
No file chosen
The file will be deleted after review and your name will be added to a list of approved visitors.