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Health Declaration Form

I hereby certify, represent as follows:

Within the fourteen (14) days immediately preceding the Date of Health Declaration Form, I HAVE NOT

  1. Tested positive or presumptively positive with the Coronavirus or have identified as a potential carrier of the COVID-19 virus or similar communicable illness.

  2. Experienced any symptoms commonly associated with the Coronavirus.

  3. Been outside of the United States

  4. Been in direct contact with or the immediate vicinity of any person I knew and/or now know to be carrying the Coronavirus or have traveled outside the United States within the last 14-days.

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