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COVID-19 HEALTH SURVEY

Please complete the form below within 12 hours of your arrival at Full Moon Resort

If the answer to any of the questions below is yes, please call (845) 254-8009 as soon as possible

Name

First Name

Last Name

Which Event You Are Attending?

Select One

Are you experiencing, or have you experienced in the past 14 days, any of the following symptoms?

-Fever (100.4 degrees or higher) -Cough -Shortness of Breath -New loss of taste or smell -Chills -Head or muscle aches -Nausea, diarrhea, vomiting

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

Have you tested POSITIVE for COVID-19 in the past 14 days?

Are you in compliance with New York State Travel Guidelines?

For up to date NYS travel information, please visit: https://coronavirus.health.ny.gov/covid-19-travel-advisory

Emergency Contact:

Please provide the name and contact information for the person you would like us to contact in the event of an emergency.

I hereby certify that the responses provided are true and accurate to the best of my knowledge. Further, I agree to provide proof of a negative COVID-19 PCR test taken within 72 hours of my arrival at Full Moon Resort and to participate in a health screening at check in.

I Agree

COVID-19 HEALTH SURVEY

Please complete the form below within 12 hours of your arrival at Full Moon Resort

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