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Personal Care Attendant VAMS Enrollment

This form is for Personal Care Attendants in order to ensure that they are able to receive vaccine during Phase 1a

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  I warrant and declare under penalty of perjury under the law of Connecticut that each of persons listed herein are eligible to receive vaccine during Phase 1a. I am aware that the submission of a false statement to the Department of Public Health is subject to the penalties of false statement pursuant to Conn. Gen. Stat. § 19a-500 and § 53a-157b.
* - Información requerida

Registro al VAMS para asistentes de cuidado personal

Este formulario es para los asistentes de cuidado personal con el fin de garantizar que puedan recibir la vacuna durante la Fase 1a

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  Declaro que soy asistente de cuidado personal en el estado de Connecticut. Entiendo que la presentación de una declaración falsa al Departamento de Salud Pública está sujeta a sanciones ".