Movement Research collects COVID-19 Vaccine Verification Form for internal use only. As of September 13th, 2021, all individuals visiting a Movement Research location must:

  • Be fully vaccinated (i.e., two weeks following receiving both doses of a two-dose vaccine or a single dose of a one-dose vaccine) with a COVID-19 vaccine authorized for emergency use by the FDA or WHO , and
  • Must provide proof of vaccination at least 48 hours in advance by completing this form. As stated in the Key to NYC guidelines, proof of vaccination includes: CDC vaccination card (A photo or photocopy of this card is also acceptable); NYC Vaccination Record (A photo or photocopy of this card is also acceptable); NYC COVID Safe App; Excelsior Pass
  • Individuals must also provide a form of photo identification, which may include driver’s license, passport, government issued ID, school issued ID, or work issued ID card.

In addition:

  • Anyone accessing the 122 Community Center building Monday to Sunday between 12pm-5pm, needs to complete this form and display their proof of vaccination and photo ID as they enter the building.
  • As MR programs are specifically designed to serve adult populations, unvaccinated children are not permitted on-site at this time, unless an exception is cleared with MR Staff in advance.
  • As per Key to NYC guidelines, any individual who submits falsified vaccination records will not be permitted to enter the facility.

If you experience any technical difficulties completing this form, please contact Submittable's customer support: https://www.submittable.com/help/submitter/

Movement Research collects COVID-19 Vaccine Verification Form for internal use only. As of September 13th, 2021, all individuals visiting a Movement Research location must:

  • Be fully vaccinated (i.e., two weeks following receiving both doses of a two-dose vaccine or a single dose of a one-dose vaccine) with a COVID-19 vaccine authorized for emergency use by the FDA or WHO , and
  • Must provide proof of vaccination at least 48 hours in advance by completing this form. As stated in the Key to NYC guidelines, proof of vaccination includes: CDC vaccination card (A photo or photocopy of this card is also acceptable); NYC Vaccination Record (A photo or photocopy of this card is also acceptable); NYC COVID Safe App; Excelsior Pass
  • Individuals must also provide a form of photo identification, which may include driver’s license, passport, government issued ID, school issued ID, or work issued ID card.

In addition:

  • Anyone accessing the 122 Community Center building Monday to Sunday between 12pm-5pm, needs to complete this form and display their proof of vaccination and photo ID as they enter the building.
  • As MR programs are specifically designed to serve adult populations, unvaccinated children are not permitted on-site at this time, unless an exception is cleared with MR Staff in advance.
  • As per Key to NYC guidelines, any individual who submits falsified vaccination records will not be permitted to enter the facility.

If you experience any technical difficulties completing this form, please contact Submittable's customer support: https://www.submittable.com/help/submitter/

Movement Research collects demographic information for internal use only. This information is used to evaluate the reach and access of our programs, and in reporting to our funders. Internal demographic evaluation and reporting with funders will be done anonymously.

We acknowledge the complexities inherent in this type of information collection and are committed to the ongoing examination of the language used around demographics. We welcome your feedback in the box at the bottom of this page.

If you are submitting this form as a part of an application, please note that the deadline for submitting this form is the same as the deadline for submitting your application. 

If you experience any technical difficulties completing this form, please contact Submittable's customer support: https://www.submittable.com/help/submitter/

Movement Research collects demographic information for internal use only. This information is used to evaluate the reach and access of our programs, and in reporting to our funders. Internal demographic evaluation and reporting with funders will be done anonymously.

We acknowledge the complexities inherent in this type of information collection and are committed to the ongoing examination of the language used around demographics. We welcome your feedback in the box at the bottom of this page.

If you are submitting this form as a part of an application, please note that the deadline for submitting this form is the same as the deadline for submitting your application. 

If you experience any technical difficulties completing this form, please contact Submittable's customer support: https://www.submittable.com/help/submitter/

Movement Research