Rebecca Holcombe for Vermont Event Participant Health Survey

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Please fill this out before attending an in-person event with Rebecca Holcombe's campaign.

Always maintain a distance of at least 6 feet from others and wear a mask or face covering.

Name *

Phone Number *

Email *

Event Name: *

Event Date: *

YYYY

In what capacity are you attending this event? *

Have you come into contact with a person who has tested positive for COVID-19 in the last 14 days? *

Yes

Are you experiencing any symptoms of COVID-19, including fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, fatigue, muscle or body aches, headache, congestion or runny nose, sore throat, new loss of taste or smell, diarrhea, or nausea or vomiting? *

Yes

If you answered yes to either of these questions, you may not attend this event. Please be in touch with your doctor. Submit this form before attending to confirm you have answered no to the above questions.

Would you like to be added to our email list?

*Please mark 'No' below if you do not wish to receive emails from the campaign

Yes

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