COVID 19 FORM - Millennium Education

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COVID 19 FORM

Millennium Education > COVID 19 FORM

COVID 19 FORM

Due to Government rules at this time concerning COVID19, we require you to fill in this form.

Be sure that the information you’ll give is accurate and complete. If you do have any of these symptoms in the last 14 days or current, we will have to ask you to
1. Not attend the event OR
2. Leave the event due to the Health regulations at present.
Please get immediate medical attention.
Full Name *

First Name Last Name
Email Address *
example@example.com
Phone Number *
Phone Number
Event Attending *
Event date *
Date Format: DD/MM/YY
Event Date

Month Day Year
Date
In the past 14 days, I have experienced...
Fever or 37C ++ Temp *

Yes No
Unexplained body aches and pain *

Yes No
Cough *

Yes No
Sore Throat *

Yes No
Shortness of breath *

Yes No
Chills with or without body aches *

Yes No
Recent loss of sense of smell or taste *

Yes No
Unexplained sores on soles of feet *

Yes No
Unusual fatigue *

Yes No
Non-allergy related runny nose *

Yes No
Should be Empty:

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