Your Name *

First Name

Last Name

Have you, any of your minor children, or anyone else living in your home tested positive for COVID-19 in the last 14 days? *

Yes

No

Have you, any of your minor children, or anyone else living in your home experienced any related symptoms of illness in the last 14 days? Symptoms of COVID-19 may include: *

Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea

Yes

No

Have you, any of your minor children, or anyone else living in your home been in close contact with anyone who has tested positive for COVID-19 or who has exhibited related symptoms? *

Yes

No

Have you or any of your minor children received an FDA-approved COVID-19 vaccine? *

Yes

No

Documentation of vaccination: *

I agree to email a copy of any certificates of FDA-approved COVID-19 vaccinations I or my minor children have received to rachel@andersonallen.com

I do not have any vaccination certificates

Verification and Acknowledgment *

I affirm that the information provided is true and accurate.

Date of Electronic Signature *

MM

DD

YYYY