Name (PRINT):

Conestoga Student Number:

Program:
Welcome to Conestoga College!

Immunizations (Form B)
Steps to Complete Requirement
Submit a copy of your COVID-19 vaccine receipt OR have your health care practitioner complete the below
documentation. This document must be signed with designation and date after each vaccine (if submitting the
form after each vaccine)
Immunization Requirement Authorization
If you are in the process of receiving your 1st and 2nd COVID-
19 vaccines, please provide documentation after each
vaccine is completed
Signature of Physician or Health
Please indicate vaccine type (Moderna, etc.) for each Care Provider:
vaccine

____________________ Date:
Date of COVID-19 Vaccine #1 Vaccine type
COVID-19
(yyyy/mm/dd) (yyyy/mm/dd)
____________________
Date of COVID-19 Vaccine #2 Vaccine type Signature of Physician or Health
Care Provider:
Per cdc.gov: If applicable:
**If student
requires TB skin Date:
testing please ____________________
complete TB Date of COVID-19 Vaccine #3 Vaccine type
Testing first, or
(yyyy/mm/dd)
defer TB Testing
4 weeks after ____________________ Office Stamp Required
vaccination**
Date of COVID-19 Vaccine #4 Vaccine type

Document Submission Process to Conestoga College

All forms are to be submitted online ONLY via the Document Submission tab in H.S.Trax.
Questions? Contact WIL Document Services, WILdocumentservices@conestogac.on.ca, 519-748-5220 extension 3101

Work-Integrated Learning (WIL) Document Requirements: Immunization (Form B)