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2. Do you have a fever greater than 100.4 degrees? Additionally, a touchless/contactless thermometer is utilized to verify each individual's temperature. Your Temp:*
4. Do you have a new cough or worsening cough (excluding chronic cough due to known medical condition)?*

   1. Yes
   2. No
6. Do you have shortness of breath or breathing difficulties?*

   1. Yes
   2. No
8. Have you had any close contact in the last 14 days with someone who has or may have a COVID-19 diagnosis?*

   1. Yes
   2. No
10. Have you traveled internationally, or to an area outside of Michigan with a high number of COVID-19 cases in the last 14 days?*

    1. Yes
    2. No
12. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
14. Electronic Signature*
16. Date*
    Date
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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