Last, First Name *

Date of Birth *

Email Address *

Phone number *

Which of the following best represents you? *

Event which you are participating in *

Do you currently have (or have had in the last 10 days) one or more of these new or worsening symptoms? A temperature equal to or above 100 degrees F; Feel feverish or have chills; Cough; Loss of taste or smell; Fatigue/feeling of tiredness; Sore throat; Shortness of breath or trouble breathing; Nausea, vomiting or diarrhea; Muscle pain or body aches; Headaches; Nasal congestion/runny nose. *

In the past 10 days, have you tested positive for COVID-19 or have you been tested for COVID-19 and you are still waiting for the result? *

In the last 10 days, have you been designated a contact of a person who tested positive for COVID-19 by a local health department? *

In the last 10 days, have you traveled internationally to a CDC Level 2 or 3 COVID-19 related travel health notice country? Further information on the NYS travel advisory can be found at https://coronavirus.health.ny.gov/covid-19-travel-advisory *