*1.Name(Required.)

*2.Phone(Required.)

*3.Email(Required.)

*4.Which program are you attending?(Required.)

*5.Do you have a cough?(Required.)

Yes

No

*6.Do you have a fever, or have you had one in the past 14-21 days?(Required.)

Yes

No

*7.Are you experiencing shortness of breath or having difficulty breathing?(Required.)

Yes

No

*8.Have you experienced recent lost sense of taste or smell?
(Required.)

Yes

No

*9.Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
(Required.)

Yes

No

*10.Have you come in contact with any confirmed or suspected COVID-19-positive people in the last 14 days?
(Required.)

Yes

No