COVID Form

* Indicates required field

What is your full name? *

First

Last

What is your phone number? *

What is your email address? *

In the last 2 weeks, have you experienced any of these symptoms? (Fever, shortness of breath, dry cough, tiredness, or any other COVID or flu symptoms?) *

Yes No

In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19? *

Yes No

List additional family members names *

By submitting this form, I declare that the information I have given is true, correct, and complete. I am aware that I may be held liable for knowingly providing incorrect information.

I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to COVID-19 measures, in accordance with the Data Privacy Act.

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