Attestation of COVID-19 Vaccination Status Form

  • Participant Information


  • In order to attend the National Alliance to End Homelessness (“the Alliance”) Conference in Washington (“Event”), I hereby attest and agree to the following:

    • 1. I have received a copy of the NATIONAL ALLIANCE TO END HOMELESSNESS MANDATORY COVID-19 VACCINATION POLICY FOR EVENTS and agree to abide by its terms as they may be modified by the Alliance.
    • 2. As of the first date of the Event, I am/will be one of the following:
      • A. “Up to date” with all vaccination requirements against COVID-19 which is defined by the Centers for Disease Control as having received all recommended doses in the primary series and 14 days after one booster when eligible.
      • B. Exempt from receiving any COVID-19 vaccine due to any of the following*:
        • i. Health Circumstance - History of previous allergic reaction to indicate an immediate hypersensitivity reaction to a component of the vaccine; health condition or medical circumstances such that immunization is not considered safe; or any other health condition or medical circumstance where receiving the COVID-19 vaccine is contraindicated; or
        • ii. Sincerely Held Religious Belief: Religious belief and/or practice which is (a) sincerely held; and (b) which prohibits receiving immunizations.
    • 3. When requested by the Alliance, I shall provide proof of my vaccination status or appropriate medical documentation from my health care provider and/or other additional information that the Alliance may require to substantiate my status.

    I declare under penalty of perjury under the laws of the United States of America that the foregoing statements are true and correct.

    * If you are requesting a medical or religious exemption, please email prior to July 13th for further guidance on required documentation.