Walkup Visitor Registration Form

Date
Date Format: MM slash DD slash YYYY
Entry Time

: HH

MM
Name
First Last
Name(s) of any additional people in your group
Phone
Email
Consent*
Verify Lack of Known COVID19 Symptoms
By signing this, I verify that I do not/am not currently experiencing any of the following symptoms and do not know to be sick:
Fever
Chills
Cough
Shortness of Breath
Fatigue
Muscle/Body Aches
Headache
New loss of taste or smell
Sore throat
Congestion/runny nose
Nausea/Vomiting
Diarrhea
Been in contact with a COVID+ person in the last 14 days
Traveled to an area of high COVID cases in the last 14 days
Traveled from outside MA or returned to MA in the last 14 days from a state other than the following: CT, District of Columbia, ME, NH, NY, or VT (as of 10.6.20)
Please initial to acknowledge your consent.*