Kulanu/TLC COVID-19 Vaccination Form

Effective September 1, it is Bet Torah policy that everyone who is eligible to be vaccinated, be vaccinated, including the 12 and up age group, in order to enter the building or participate in any Bet Torah programming indoors.

Children who are 12 must be vaccinated by 2 months following their 12th birthday to enter or participate in any Bet Torah program.

"*" indicates required fields

Please out this form once for each teen (ages 12+) in the family.
Teen Name*
Will this teen be fully vaccinated against COVID-19 as of September 1, 2021?*
MM slash DD slash YYYY
Name of parent/guardian filling out this form
This field is for validation purposes and should be left unchanged.