EUPC Service Pre-Registration Form

EUPC INHOUSE MEETINGS/GATHERINGS PRE-REGISTRATION FORM

Please complete the form and questionnaire below to attend any inhouse meetings and/or gatherings.

Attendance will be limited to ensure physical distancing and Facemasks are required!

* Indicates required field

Event Name: *

Date of the Event *

Attendee's Name *

First

Last

Please list the name of other attendees:

Name *

First

Last

Name *

First

Last

Name *

First

Last

Name *

First

Last

Please provide the preferred contact number:

Home Number *

Cell Number *

Email *

Please answer the following questions:

In the last 14 days, have you tested positive for COVID-19? *

Yes No

In the last 14 days, have you been in close contact with anyone who: tested positive for COVID-19, been told to self-quarantine or waiting for COVID-19 test results? *

Yes No

In the last 14 days have you experienced any symptoms (not due to pre-existing condition) such as fever, cough, shortness of breath, sore throat, nausea, vomiting, diarrhea, or loss of taste or smell? *

Yes No

In the last 14 days, have you or anyone in your household traveled outside the United States? *

Yes No

If you answered Yes to any of these questions, out of an abundance of caution, we respectfully ask that you do not attend the meeting and/or event.

Once you submit your form, you will get a message "Thank you. Your information has been submitted and you will receive a confirmation email".

Submit