In-Person Gathering Health Screening Form

All attendees are required to answer a series of health screening questions prior to any gathering participation. By execution of this Statement, I affirm that my answer is “No” to each of the foregoing questions. I understand that if my answer to any of the foregoing questions is “Yes,” I am not permitted to attend.

Event Health Screening Questionnaire

Event Health Form - North Broward Schmooze & Booze

Name(Required)
Have you had a fever during the past 24 hours?(Required)
Have you had a new or unexpected cough during the past 7 days?(Required)
Have you exhibited any of the number of symptoms published by the Centers for Disease Control and Prevention as consistent with a COVID-19 diagnosis?(Required)
Have you been around anyone exhibiting these symptoms within the past 14 days?(Required)
Are you living with anyone who has been sick, has exhibited symptoms of COVID-19, or is currently under quarantine for exposure to COVID-19?(Required)
Are you currently quarantining, been asked to quarantine, or been suggested to quarantine within the last 14 days?(Required)