covid form | VLADANCE

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

I am not experiencing symptoms of covid: fever, cough, sore throat

I have not had “close contact” with an individual diagnosed with COVID-1ε. “Close contact” means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within 6-feet of a person who has tested positive for COVID-19 for about 15 minutes, or coming in direct contact with secretions (e.g., sharing utensils, being coughed on, etc.) from a person who has tested positive for COVID-19, while that person was symptomatic.

I will get my temperature checked upon arriving to rehearsal, if it's above 100.3 degrees I will go home.

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!