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Staff Development Center (SDC)

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Check If This Is A Minor?

Is minor

(Guardian information required for minors under the age of 18)

Guardian Name

Guardian Email

Guardian Email Confirmation

Guardian Phone

First Name

Middle Name

Last Name

Date of Birth

Gender

Male

Female

Other

Race

Asian or Pacific Islander

Black or African American

Hispanic

Native American

White

Other

Decline to state

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

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Primary Language

Classification

Custom classification

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Email

Email confirmation

Create account with an email address

Username

Username confirmation

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Minimum 8 characters with at least one digit (0-9),
one alpha (a-z) and one special character (!, @, #, $, %, &, *)

Password Confirmation

Mobile Phone: *

Telephone

Address1

Address2

City

County

County

State

State

State / Province / Region

State

Zipi.e. 90001 Zip / Postal Code(numbers only, no spaces)

Zip

Country

Locations

Custom location

Have you received at least one dose of the Covid-19 vaccine?

Yes

No

Vaccination Details

Manufacturer

1st Dose Date *

1st Dose Lot Number

2nd Dose Date

2nd Dose Lot Number

Booster Date

Booster Lot Number

Vaccine Card *

Vaccine Card (front)

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(gif, heic, heif, jpeg, jpg, png)

Vaccine Card (back)

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Contact Us

+1 (833) 526 7667
support@cosmoshealthsolutions.com

Address

13552 Newport Ave Tustin, CA 92780
English | Spanish

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