COVID-19

COVID-19

Please complete if you have tested positive for COVID-19, please do not come into the office. You can also call us at 480-982-4811 or email the General Manager at roadhavengm@gmail.com . You will remain anonymous; no person’s name shall be released.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Park Address*
- If you have tested positive, you must remain in your home at all times. If you must leave your home for any reason wear a mask.
- If you do need someone to pick up groceries or medication, call the front office and we can get someone to do this for you. You can also order groceries online for delivery from Frys, Safeway, and Bashas.
- Once you have been tested negative, let the office know so that we can record this on our records.
Date you first starting feeling ill (estimated)*

MonthDayYear
Date
Date tested for COVID-19*

MonthDayYear
Date
Date you'll be retested for COVID-19 (estimated)*
Signature*

Clear
Date

MonthDayYear
Date
You consent and agree that your use of a keypad, mouse, or other device to select an item, button, icon, or similar act/action while using any electronic service we offer; constitutes your signature, acceptance, and agreement as if signed by you in writing. Further, you agree that no certification authority or other third-party verification is necessary to validate your electronic signature; and that the lack of such certification or third-party verification will not in any way affect the enforceability of your signature or resulting contract between you and Roadhaven. You understand and agree that your eSignature executed in conjunction with the electronic submission of this form will be legally binding and such transaction will be considered authorized by you and constitutes your agreement to be bound by the terms and conditions of the electronic service as they exist on the date of your eSignature on this form.
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