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* 1. Name:

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* 2. Do you have any children aged 17 and under connected to your household? If so how many?

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* 3. Please check the box if you have any of the following symptoms:

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* 4. Have you been in close contact with a person that tested positive for Covid-19?

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* 5. Have you received a positive Covid-19 test within the last 5 days?

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