Dancer Details

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

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Your legal name

Your email address

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

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I agree that I am and I understand this is a legal representation of my signature

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Signature Certificate

Document name: COVID-19 Medical Exemption Form - 22-23 School Year

Unique Document ID: 6259e369605f62507d40ec15e17cf20a99d09ad9

Build. Track. Sign Contracts.

Timestamp	Audit
August 16, 2022 8:02 pm EDT	COVID-19 Medical Exemption Form - 22-23 School Year Uploaded by Gail D'Addario - [email protected] IP 172.119.197.59
August 16, 2022 8:04 pm EDT	Nancy Cole - [email protected] added by Gail D'Addario - suppor[email protected] as a CC'd Recipient Ip: 172.119.197.59
November 21, 2022 10:24 am EDT	Nancy Cole - [email protected] added by Gail D'Addario - suppor[email protected] as a CC'd Recipient Ip: 172.119.197.59
November 21, 2022 10:33 am EDT	Nancy Cole - [email protected] added by Gail D'Addario - suppor[email protected] as a CC'd Recipient Ip: 172.119.197.59

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://www.joffreyballetschool.com/

Audit Trail Serial# bc1d01d02a506e02b37d61fc907de317