COVID SCREENING

First Name(Required)

Last Name(Required)

Phone Number(Required)

Email(Required)

Have you or anyone in your household had a fever of 100.4 or higher during the past two weeks?(Required)

Includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you or anyone in your household had a cough or unusual shortness of breath during the past two weeks?(Required)

includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you or anyone in your household tested for COVID-19 during the past two weeks?(Required)

includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you or anyone in your household traveled to a region/country considered high risk exposure to COVID-19 in the past two weeks?(Required)

includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

More info, please review

Has anyone in your household been exposed to anyone who has tested positive for COVID-19 in the past two weeks?(Required)

Includes anyone you associate with on a regular basis (examples: your colleagues at work and/or friend/s)

Have you received the COVID vaccine?(Required)

How many doses of the COVID vaccine have you received?(Required)

By signing below:(Required)

I agree that I have entered honest and correct answers to the best of my knowledge.

I agree that I must report changes to the information listed on this form prior to the start of each Face2Face class session

Signature(Required)