To ensure the safety of all involved please read and answer the following questions honestly.Full Name:*First NameLast NameHave you experienced any of the following symptoms in the past 48 hours?*Please select all that apply.Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaNoneWithin the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?*YesNoAre you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?*YesNoAre you currently waiting on the results of a COVID-19 test?*YesNoIf your response to any of the following questions is YES, we ask you to please not attend CTeen for the time being.Please confirm that should the answer to the above questions change, AFTER having submitted this form, please do not attend for the time being. Should you be showing symptoms of COVID-19 up to a week after attending a CTeen event, please notify us immediately so we may respond accordingly.Signature:*Date:*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearSubmitShould be Empty: This page uses TLS encryption to keep your data secure.