Name *

First Name

Last Name

Have you traveled or been in contact with someone has have traveled outside the Hamilton area in the last 14 days? *

Yes

No

Have you or any member in your family been in close contact with a person(s) diagnosed with or person(s) suspected with Covid-19 or person(s) who have been quarantined at home during the last 14 days? *

Yes

No

Have you experienced any of the following in the last 14 days? *

Fever (100.4 F or high)

Shortness of breath

Sore throat

Repeated shaking with chills

Muscle pain

Runny nose

Cough

Chills

Headache

New loss of taste or smell

None of the above

Disclosure *

This information will be maintained in confidence and only shared internally on a need-to-know basis, unless otherwise required/advised to be disclosed. By submitting you information, you agree and consent to The Gate collecting, using, and disclosing the information as required, advised or directed by federal, state, or law or governmental authorities. I hereby waive, discharge, and release The Gate from all claims and liability in connection herewith. I certify the above information is true, and that I consent to the information being used a specified

I consent