Client COVID-19 Vaccine Verification Form

To comply with the Seattle & King County Local Health Officer Verification of Vaccination Order going into effect on October 25, 2021, Safe N Sound is now required to verify vaccination or a negative COVID-19 test for all persons ages 12+ entering the facility.

To streamline the verification process, we ask you to fill out our Client Vaccine Verification Form and upload a picture of proof of vaccination for any and all persons age 12+ that may attend swim lessons. This includes:
• Parents
• Siblings ages 12+
• Grandparents
• Nannies
• Carpool drivers

Parent/Guardian Name: Parent/Guardian Name: First Last
Email:
List your swimmer(s) name(s) separated by commas:
Please list the names of anyone who currently attends or may attend swim lessons with your swimmer in the future. Please separate names with commas:
Will you and anyone (ages 12+) who will be accompanying your swimmer to lessons be fully vaccinated by October 25th, 2021?

Will you and anyone (ages 12+) who will be accompanying your swimmer to lessons be fully vaccinated by October 25th, 2021? Yes No
Per the King County vaccine mandate, any person aged 12 and over will be required to show proof of their full COVID-19 vaccination status, or a negative COVID-19 test, to enter the Safe N Sound facility. Please upload proof of vaccination for each person listed above:

Attach Files
Do you agree to comply with the Public Health-Seattle & King County COVID-19 vaccination verification mandate and provide Safe N Sound with a negative PCR COVID-19 test completed within 72 hours of entering the facility?

Do you agree to comply with the Public Health-Seattle & King County COVID-19 vaccination verification mandate and provide Safe N Sound with a negative PCR COVID-19 test completed within 72 hours of entering the facility? Yes No
Please upload a photo of your negative COVID-19 test, dated within 72 hours of your next scheduled service at Safe N Sound:

Attach Files
You have indicated that you will not be complying with the Public Health-Seattle & King County COVID-19 vaccination verification mandate, therefore, your swimmer will be removed from our schedule. Please indicate what date you would like as their final lesson: You have indicated that you will not be complying with the Public Health-Seattle & King County COVID-19 vaccination verification mandate, therefore, your swimmer will be removed from our schedule. Please indicate what date you would like as their final lesson: / MM / DD YYYY
I understand and acknowledge that by signing in the box below, that I am legally agreeing to all of the statements in this document.

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