We encourage you to please complete this form if you are planning a return, either as a coworker or as a member.

The form is created to give us a sense of your planned return activities and timing. 

In addition, we are also surveying 10C community vaccination status so that we may begin to establish and share a percent (%) of people vaccinated, as one of the methods to communicate about safety and risk at 10C.

Individual vaccination information collected in this survey will be confidential to 10C’s leadership team, Associate Director, Katie Baikie and Executive Director, Julia Grady, and will only be used to help inform our safety policies and procedures for our collective wellbeing.

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* 1. Name

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* 2. Affiliation (if applicable)

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* 3. I'm excited to return to 10C for: (check all that apply)

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* 4. I wish to return in-person to 10C:

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* 5. At this time, I am comfortable disclosing my COVID-19 vaccination status.

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* 6. If yes above, please indicate your COVID-19 vaccination status.

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