COVID-19 Medical Exemption Form - 22-23 School Year


Dancer Details

First Name:  
Middle Name:  
Last Name:   
Date of Birth (mm/dd/yy):

Program

Parent/Guardian Details

Parent/Guardian First Name:  
Parent/Guardian Middle Name:  
Parent/Guardian Last Name:  

Relationship to Student:

Supporting Documentation
Please upload supporting documentation from a licensed physician, physician's assistant, or nurse practitioner.

Statement of Exemption

By completing this form, I certify that different methods of vaccinating against COVID-19 have been considered, and that the following medical contraindication precludes any/all vaccinations for COVID-19.

Leave this empty:

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Signature Certificate
Document name: COVID-19 Medical Exemption Form - 22-23 School Year
lock iconUnique Document ID: 6259e369605f62507d40ec15e17cf20a99d09ad9
Timestamp Audit
August 16, 2022 8:02 pm ESTCOVID-19 Medical Exemption Form - 22-23 School Year Uploaded by Gail D'Addario - support@joffreyballetschool.com IP 172.119.197.59
August 16, 2022 8:04 pm ESTNancy Cole - ncole@joffreyballetschool.com added by Gail D'Addario - support@joffreyballetschool.com as a CC'd Recipient Ip: 172.119.197.59
November 21, 2022 10:24 am ESTNancy Cole - ncole@joffreyballetschool.com added by Gail D'Addario - support@joffreyballetschool.com as a CC'd Recipient Ip: 172.119.197.59
November 21, 2022 10:33 am ESTNancy Cole - ncole@joffreyballetschool.com added by Gail D'Addario - support@joffreyballetschool.com as a CC'd Recipient Ip: 172.119.197.59