Proof of Vaccination Student Incentive

Spoon River College is committed to the health and safety of our students and employees. Supporting and encouraging the vaccination of employees and students plays a crucial role in a safe Fall 2021 semester and in ending the pandemic. Vaccinated students help protect others and also help the world transition to a post-pandemic future.

Your commitment to your health and the health and safety of others is greatly appreciated. Fully vaccinated students who provide proof of vaccination are eligible to receive a $100 incentive. In order to receive the incentive, you must have both doses of Moderna or Pfizer or a single dose of Johnson & Johnson and provide proof of vaccination.

As a reminder, all people, regardless of vaccination status, are required to wear face-coverings in indoor public spaces throughout campus, including classrooms.

Eligibility:

This incentive is open to Spoon River College Adult Education students who meet the following criteria:
Enrolled in Fall 2021 semester
Attend 12 or more hours of in-person class (online/remote students are not eligible)

Student First Name: *

Student Last Name: *

Student ID Number: *

Student Email Address: *

Vaccine: Product Name/Manufacturer *

1st Dose Lot # *

First Dose Date * +

1st Dose Health Care Professional or Clinic Site *

2nd Dose Lot # *

Second Dose Date * +

2nd Dose Health Care Professional or Clinic Site *

Student Date of Birth * +

Today's Date * +

Incentive checks will be mailed to the address provided at the time of enrollment. Students needing assistance in completing the incentive form are encouraged to speak to an Adult Education Program Advisor Melissa Koke or Molly Smith.

Agree

Proof of Vaccination - A clear photo of front and back of vaccination card is sufficient. *

Questions about this form? Contact Katey Davis.