Name:

Phone Number:

Email address:

Have you experienced any of the following symptoms in the past 24 hours:

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?

Are you currently waiting on the results of a COVID-19 test?

Pls enter the temperature read out of the electronic temperature reader

I certify to the best of my knowledge that the information above is accurate

I acknowledge the following:

By entering, I also acknowledge that I will observe the guest rules and policy of COHAUS which include:

- being accompanied by the COHAUS member of whom you are a guest at all times and
- having access to only the private bedroom of the COHAUS member you know or outdoor spaces. Access to common areas like kitchen and sitting areas will be restricted during the health pandemic.

If you answered yes to any of the questions above, please do not enter this facility.