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BENEDICT COLLEGE

COVID 2nd-Dose Agreement

All students are required to achieve 100% vaccination in order to participate in Fall 2022 courses and activities. However, students who you have had their first dose and are waiting to obtain their second shot may be allowed to report to campus by completing this form and complying with all requirements explained below.

Please note that the last date to obtain the first dose of the Pzfizer, Novavax or Astrazeneca in time to meet the September 2nd deadline is Friday, August 12th. The last date for Moderna is August 5th.

Date

8/15/2022

Student Name

guest guest

Student ID Number

0

Email

*

Phone Number:

*

Which vaccine did you receive for your first dose?

*

Please provide the date of your first shot:

Do you intend to return home to obtain your second shot?

Please upload a copy of your COVID Vaccination card or other official documentation of your first shot. Please be sure that your uploaded image is clear and legible.

Choose a file

You must agree to each of the following statements in order to report to campus:

I agree

I confirm that I have cleared the Student Accounts module in the Tiger Portal.

*

I agree

I understand that I will be required to test weekly (at my expense) and to report my negative test results to the Health Center.

*

I agree

I understand that failure to comply with all directives from the Student Health Center, including testing requirements and vaccination appointments, may result in my withdrawal from the college. (Withdrawal will result in pro-rated tuition, fee, and room and board charges.)

*

I agree

I understand that I will be withdrawn from my classes and removed from the residence hall if I do not receive my 2nd shot by September 2, 2021 and that I will be charged tuition, room and board fees at a pro-rated amount.

*