Food distribution Volunteer release form

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You are signing up to volunteer for a collaborative. In an effort to reduce the spread of COVID19, please fill out this form. Please note that you may not be able to volunteer if you are sick or have been exposed to COVID19. You acknowledge that you are participating at your own risk, and you waive any responsibility to the volunteers, staff, and organizations involved in preparing, packing, and distributing the products.

Intentamos reducir las transmisión de COVID19. Por favor, rellene este formulario. Usted reconoce que participa bajo su propio riesgo y libera de cualquier responsabilidad a los voluntarios, personal y organizaciones involucradas en preparar, empacar, y distribuir los productos.

You may be asked the same questions on site.

For any questions about this form please email mguerre3@jhmi.edu

First Name/Nombre *

Last name/Apellido *

Phone number/Telefono *

Are you showing any of the following symptoms: fever, cough, sore throat, shortness of breath, acute loss of taste or smell, headache, diarrhea, or muscle aches? /// Presenta sintomas como: fiebre, tos, dolor de garganta, falta de aire al respirar, perdidade sabor u olor, dolor de cabeza, diarrea o dolor muscular? *

Yes/Si

Is someone in your home showing any of the following symptoms: fever, cough, sore throat, shortness of breath, acute loss of taste or smell, headache, diarrhea, or muscle aches? ////// Tiene en su casa a alguien con los siguiente sintomas: fiebre, tos, dolor de garganta, falta de aire al respirar, perdidade sabor u olor, dolor de cabeza, diarrea o dolor muscular? *

Yes/Si

Have you visited an ER, hospital, or urgent care center (e.g. PatientFirst) within the last 14 days? //// Ha tenido que ir a urgencias, hospital o cuidado urgente (como Patient First) en los ultimos 14 dias? *

Yes/Si

Have you knowingly had contact with someone who visited an ER, hospital, or urgent care center within the last 14 days? //// Ha estado en contacto con alguien que haya estado en urgencia, hospital o cuidado urgente en los últimos 14 días? *

Yes/Si

Have you knowingly had contact with someone who tested positive for COVID-19 or is experiencing fever, cough or shortness of breath? ////// Ha estado en contacto con alguien que haya dado positivo en el test de COVID19 o ha experimentado fiebre, tos o dificultad para respirar? *

Yes/Si

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