Traveler Health Form

Traveler Health Form
One form per adult required. Children or other dependents traveling with you can be included with one adult.
Personal & Contact Information
Name
First NameLast Name
Birth Date
MonthDayYear
Gender
MaleFemaleN/A
Email
example@example.com
Phone Number
Please enter a valid phone number.
Primary Language
Child/Dependent

Trip Information
Date of Arrival
MonthDayYear
Date
Date of Return
MonthDayYear
Date
Travel Method
AirplaneBusPrivate vehiclePublic transportShipTrainOther
Where will you stay?
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Final Destination

Exemptions & Attestation
- Non-essentail travel is discouraged.
- Essential workers form other states and countries are not required to quarantine.
- Travelers passing through another state or country for less than 24 hours, other than in the course of travel, are not required to quarantine. However, the traveler must take a COVID-19 test 4 days after their arrival.
- All other travelers that are asymptomatic are required to quarantine for 10 days if they do not test prior to departure and on day 4 after arrival.
Attestation
I hereby attest, under penalty of law, that all information that I have provided is true and accurate to the best of my knowledge.
Should be Empty: