COVID-19 Wellness Check

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Email *

Date of today's class or service. *

YYYY

Full name (first and last) *

Have you had any symptoms of COVID-19 within the past 14 days, including: Fever (100.4 F or greater), chills, cough, shortness of breath or difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea? *

Yes

Within the past 14 days have you been caring for or living with someone diagnosed with COVID-19 or symptoms of COVID-19. *

Yes

Within the past 14 days have you been advised to self-quarantine due to COVID-19 exposure? *

Yes

Thank you for helping us to keep our community safe and for your continuing support!

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