Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have a fever of 100.4 F or higher? *

Yes

No

Do you have a cough? *

Yes

No

Do you have shortness of breath? *

Yes

No

Are you feeling tired/fatigued or have muscle aches? *

Yes

No

Do you have a new loss of taste or smell? *

Yes

No

Have you been in close contact with anyone who has tested positive for Covid-19? *

Yes

No

Have you had a positive Covid-19 test for active virus in the past 10 days? *

Yes

No

With in the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self quarantine because of concerns about Covid-19? *

Yes

No

If at any point in time I learn that I have been exposed to someone who is exhibiting symptoms or who has tested positive, I understand that I am required to notify my instructor immediately. *

I agree to notify my instructor.