Name *

First Name

Last Name

Phone *

(###)

###

####

Are you a member of HICCC? *

Yes

No

COVID-19 Symptoms *

COVID-19 symptoms include: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, severe headaches, loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. Are you or anyone you are checking in feeling ill?

Yes

No

Potential Contact *

In the last two weeks, have you or anyone you are checking in been in close contact with someone who has COVID-19 or who has been experiencing the above symptoms?

Yes

No

COVID Exposure *

Are you (or anyone you are checking in) awaiting the results of a recent COVID-19 test because of symptoms or exposure?

Yes

No

Recent Travel *

In the last 10 days, have you or your family traveled outside of California or the U.S.?

Yes

No

Mask Requirement *

I understand that I/we will be required to wear a face covering and maintain social distance while on HICCC premises

Yes