HH-Form-00001: Historic Haven COVID-19 Business Operations Intake Form

Date/Time:____________________________________________________________

Customer/Patron/Owner/Staff Name:______________________________________

Email:________________________________________________________________

Have you traveled to an area of concern in the last 30days? Y/N (circle one)

If yes, location:________________________________________________________

Have you had contact with a known case of COVID-19 in the last 30days? Y/N (circle one)

Have you tested positive for Sars-CoV-2 (aka COVID-19) in the last 30days? Y/N (circle one)

Do you currently have a fever (a body temperature of 100.4F or higher)? Y/N (circle one)

Do you currently have a cough, congestion, or difficulty breathing? Y/N (circle one)

If yes, which one(s)_____________________________________________________

Do you have any body aches, chills, or headache? Y/N (circle one)

If yes, which one(s):____________________________________________________

Signature:_____________________________________________________________

By signing, I attest that all the above information is truthful and reliable. By signing, I agree that the Historic Haven Owners reserve the right to deny me entry onto/into the premises for any reason without disclosing that reason. By signing, I agree that the Historic Haven Owners reserve the right to remove me from the premises at any moment for any reason without disclosing that reason. By signing, I agree to abide by all rules, regulations, and requirements set out/forth by the Owners of the Historic Haven. By signing, I release any responsibility to the above information to the Historic Haven for their use as they see fit.