Name *

First Name

Last Name

Phone *

Your phone number is needed in case we have any questions and/or we need to followup with any contact tracing.

(###)

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Are you experiencing any of the following symptoms: *

- Cough - Feeling feverish or a measured temperature greater than or equal to 100°F - Shortness of breath - Chills - Repeated shaking with chills - Muscle pain - Headache - Sore throat - Loss of taste or smell - Diarrhea

Yes

No

Have you been in close contact with (within 10 feet of) anyone with COVID-19 in the past two weeks? *

Yes

No

Do you understand that masks are required for all in-person events (outdoor and in-door), that social distancing is required, and that participation will be limited?

If you agree to follow the UCM health and wellness guidelines, click yes and submit form.

Yes

No