COVID-19 Health Declaration | The Chinese Language Institute

Participant Information

Name *

First

Last

Date of Birth *

Email *

Program Name *

Vaccination Information

I am vaccinated against COVID-19: *

1 vaccine dose
2 vaccine doses
3 or more vaccine doses
I am not vaccinated against COVID-19

Vaccination Card Scan *

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Please upload a clear photo or scan of the front of your Covid-19 vaccination card (link opens in new tab).

Participant Signature

I declare that: *

My information as entered above is accurate and correct to the best of my knowledge.
If I learn that I came into contact with someone within 14 days of my CLI program start date who is confirmed to have COVID-19, I will inform CLI's Admissions Manager prior to program start date.
I authorize CLI to share my vaccination card scan and status with my program's faculty leader(s), relevant administrators, and relevant personnel.
I have read and agree to adhere to CLI’s COVID-19 Policies and Protocols (link opens in new tab) for the duration of my program.
If I test positive for COVID-19 during the program, I authorize CLI to receive and share my COVID-19 test results with the program's faculty leader(s), relevant administrators, and relevant personnel.

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