Temple Israel Vaccination Affirmation

Join Us at Temple Israel!

We want to make sure that everyone stays safe and healthy, so please complete the form below, verifying that you are FULLY vaccinated. (By FULLY vaccinated we mean two weeks from your second dose of the Pfizer or Moderna vaccines and two weeks from your single dose of the Johnson & Johnson vaccine.)

This vaccine affirmation will be kept on file, so you will only have to complete it one time for all services, classes, and other activities and events.

In accordance with recent recommendations from the CDC, we are also requiring that all persons wear masks inside the Temple Israel building.

If you have any questions at all you can contact the Temple business office or Lisa Slaton at admin@templeisraeltlh.org .

* First Name

* Last Name

* Phone Number

* Email

* Names of vaccinated people in your group (ages 5 and older)

Please separate names with a ,

Names of vaccinated people in your group who have received their booster shot

Please separate names with a ,

* Please check this box if you have been fully vaccinated.

Please check this box if you have been fully vaccinated.I hereby affirm that I/we have been fully vaccinated - at least two weeks past second dose of Moderna or Pfizer vaccines, or two weeks past single dose of Johnson & Johnson vaccine At this time, vaccines are required for attendance at in-person services.

Tue, May 17 2022 16 Iyar 5782