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12/30 Frostburg City COVID Testing Sign-ups
Please complete all required fields to sign up employees for COVID Testing 3
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* Indicates required question
Name of Business
*
Your answer
Business Contact Name
*
Your answer
Business Contact Cell
*
Your answer
Business Contact Email
*
Your answer
Employee's First Name
*
Your answer
Employee's Last Name
*
Your answer
Employee's Date of Birth
*
MM
/
DD
/
YYYY
Employee's Gender
*
Female
Male
Employee's 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
Employee's Street Address
*
Your answer
Employee's City
*
Your answer
Employee's State
*
Your answer
Employee's Zip Code
*
Your answer
Employee's Ethnicity
*
Hispanic
Not Hispanic
Unknown
Have you tested positive in the past 90 days?
*
Yes
No
Employee's 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
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