Proof of Vaccination or Negative COVID-19 Test

This form must be submitted prior to your arrival on campus for the 2021 GSSE program. We ask that you submit the form no later than Friday, May 28.

Student Name*
First Middle Last
Birth Date*
Month
Day
Year
Student Email*
Name of Responsible Adult
First Last
Has the student ever had a positive COVID-19 test?*
Provide the date of the positive COVID-19 test:*
Month
Day
Year
I am providing proof of:*
Date the test was administered:*
Please provide name and address of where the test was administered:*
Vaccination Date, Dose 1*
Month
Day
Year
Vaccination Date Dose 2 (if applicable)
Month
Day
Year
Name of location where vaccine was administered:*
Upload documentation of negative test or vaccination record
Max. file size: 2 MB.
Comments:
*
- The information I am providing on this form is true and accurate.

Governor’s School for the Sciences and Engineering Pre-college Research Excellence Programs