Health Declaration

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

Have you traveled outside New York State in the last three weeks?

No

Yes

Check all that apply

I don't have any flu symptoms..sore throat,cough,chills

No one in my house has Covid 19 or symptoms

I've had no contact with anyone who is Covid Positive or exhibiting symptoms

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting!

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