Name *

First Name

Last Name

Today's Date

MM

DD

YYYY

First Date of your Trip with us

MM

DD

YYYY

Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt "feverish" or had a temperature that is elevated for you/100.0F or greater? *

Yes

No

Do you have any of the following symptoms?

Cough

Shortness of Breath or Chest Tightness

Sore Throat

Nasal Congestion/Runny Nose

Myalgia (Body Aches)

Loss of Taste and/or Smell

Diarrhea

Nausea

Vomiting

Fever/Chills/Sweats

Have you traveled internationally or outside of the state in the last 14 days? Or, have you had any close contact in the last 14 days with someone with a diagnosis of COVID-19? *

Yes

No