Coronavirus Self Declaration Form
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Are you ill, or been in contact with people infected or suspected to be positive for COVID-19?
Your relationship with them and your last contact date
Please state whether you've experienced/are experiencing the following
Shortness of Breath
Persistent Pain in the Chest
New Loss of Taste or Smell
Unexplained lesions on toes
I acknowledge that the information I've given is accurate and complete.
Should be Empty: