Name
(Required)
First
Middle
Last
Date of Birth
(Required)
DD slash MM slash YYYY
Primary Contact Number
(Required)
Email
(Required)
Manager’s Name/ Primary contact at LIFE if you’re a LLC Student or a contractor
(Required)
Department
(Required)
Business Support Services
Programming
Communications
People
LIFE Leadership College
Community
LIFE Venues
Are you vaccinated against COVID-19?
(Required)
Yes - first dose
Yes - fully vaccinated
No
Date of your first dose
(Required)
DD slash MM slash YYYY
Date of your second dose
(Required)
DD slash MM slash YYYY
If you have not yet received your second dose of COVID-19, what is the latest date by which you can receive this dose? (This is 6 weeks post your first dose)
(Required)
DD slash MM slash YYYY
Name of the COVID-19 vaccine you have received
(Required)
Please check your vaccine card for this detail
Please upload a copy of your COVID-19 vaccination record or pass
Max. file size: 128 MB.
Are you intending to be vaccinated for COVID-19
Yes
No
Are you are exempt from receiving a COVID-19 vaccination, under clause 7A or 12A, or an authorisation under clause 9 or 9A of the COVID-19 Public Health Response (Vaccinations) Amendment Order (No 3) 2021?
(Required)
Yes
No
If you are exempt from receiving a COVID-19 vaccination, please upload a copy of your exemption or authorisation for the fact
Max. file size: 128 MB.
If you are not vaccinated against COVID-19, and plan to be, what is the latest date by which you must receive your:
Hidden
First Dose
DD slash MM slash YYYY
Hidden
Second Dose
DD slash MM slash YYYY
If any of the information you have provided changes, you must notify your Manager as soon as practicable after it changes.
(Required)
I agree
I confirm that all the information I have provided is true and accurate
(Required)
I agree
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www.lifenz.org/privacy
