Covid Event Reporting Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Dates of Attendance* This field is required.If you attended multiple dates within window of contact, please select all that apply.

YALA Baby Artsplay!, Ogden: October 28 - Workshop 1

YALA Baby Artsplay!, Ogden: November 4 - Workshop 2

YALA Baby Artsplay!, Ogden: November 11 - Workshop 3

YALA Baby Artsplay!, Ogden: November 18 - Workshop 4

YALA Baby Artsplay!, Ogden: December 2 - Workshop 5

YALA Baby Artsplay!, Ogden: December 9 - Workshop 6

YALA Artsplay!, Newcomb: November 7 - Workshop 1

YALA Artsplay!, Newcomb: November 14 - Workshop 2

YALA Artsplay!, Newcomb: November 21 - Workshop 3

YALA Artsplay!, Newcomb: November 28 - Workshop 4

YALA Artsplay!, Newcomb: December 5 - Workshop 5

YALA Artsplay!, Newcomb: December 12 - Workshop 6

5

Are you experiencing symptoms?* This field is required.

YESNO

6

Please check all that apply to you.* This field is required.

I have come within six feet for more than 15 minutes of someone who tested positive.

I think I have Covid and have not been tested.

I have been tested and given a confirmed result showing I have Covid.

7

Other notesPlease add additional information you would like us to know.