Covid Check | Hope Community, NYC

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

No one in my party has traveled to a restricted state in the last 14 days

No one in my party is experiencing the symptoms: fever, cough, sore throat

No one in my party has been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete