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12/23 Cumberland City COVID Testing Sign-ups
Please complete all required fields to sign up for COVID Testing. This drive is planned to be inside. If you would like to have your test done in your vehicle, please email Bri (
blavorgna@aeontechlabs.com
) directly to set up accommodations.
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* Indicates required question
Name of Cumberland City Employer
*
Your answer
Employer Phone Number
*
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Phone Number - Please make sure this is a working number - this number will be used to report all POSITIVE results. (Note - for minors, please use parent/guardian's phone number)
*
Your answer
Date of Birth (Day, Month, Year)
*
Your answer
Gender
*
Female
Male
Street Address
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Your answer
City
*
Your answer
State
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Your answer
Zip Code
*
Your answer
Ethnicity
*
Hispanic
Not Hispanic
Unknown
Result Preference: Please either provide your cell or email for receiving a text for negative results. All positives will be a phone call.
*
Your answer
Have you tested positive in the past 90 days?
*
Yes
No
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