COVID-19 Travel Declaration Form for Visitors

COVID-19 Travel Declaration Form for Visitors
For the health and safety of our community, we seek your cooperation to complete this form prior to your travel. Be sure that the information you give is accurate and complete. Thank you.
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Home Address
Street Address
Street Address Line 2
CityState
Zip CodeCountry
Are you living with a household member(s) under Home Quarantine Order (HQO) or Stay-Home Notice (SHN)?
YesNo
Please state whether you've experienced/are experiencing the following
Yes No
Fever
Cough
Sore throat
Runny nose
Shortness of breath
Loss of taste and smell
Arrival Date
MonthDayYear
Date
Return Date
MonthDayYear
Date
Vehicle
Personal vehiclePublic transportationBusMetroTrainOther
I acknowledge that the information I've given is accurate and complete.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: