Name *

First Name

Last Name

Phone *

(###)

###

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Are you fully vaccinated? *

Yes

No

Are you currently ill or suffering from any COVID-19 like symptoms that include a cough, sneezing, fever, sore throat, difficulty breathing. Please refer to the BC Centre for Disease Control website for a full listing of COVID-19 like symptoms *

Yes

No

Have you been in close contact with someone who has been suffering from any of the above symptoms or someone who has a confirmed or probable case of COVID-19 without appropriate PPE? *

Yes

No