FEEL TO HEAL RETREATS
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Springhill Retreat Center
Covid-19 & Health Declaration
Please complete at time of registration and again the week immediately before the retreat.
*
Indicates required field
Name
*
First
Last
Email
*
Re-enter Email
*
Phone Number
*
Re-enter Phone Number
*
Screening questions & declarations
Have you had your COVID-19 vaccinations? (not required)
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Yes both/all
Yes, just one
No
Upload vaccination docs
*
Max file size: 20MB
Have you had COVID-19 and recovered? Can you provide a negative test?
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Yes and Yes
Yes and No
No and Yes
No and No
Upload negative test result
*
Max file size: 20MB
Do you currently have a fever (greater than or equal to 100 degrees F)
*
Yes
No
In the past 48 hours, have you had NEW onset: (check all that apply)
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FEVER greater or equal to 100 degrees F
PERSISTENT cough
SHORTNESS of breath
NONE
In the past 48 hours, have you had ANY of the following symptoms?
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Chills with or without repeated shaking
Muscle aches
Sore throat
Fatigue
Nausea
Diarrhea
New loss of taste or smell
NONE
In the past 14 days, have you had KNOWN CLOSE CONTACT* with a person who has confirmed COVID-19?
*
Yes
No
In the past 14 days, have you had KNOWN CLOSE CONTACT* with a person experiencing symptoms of COVID-19?
*
Yes
No
* "CLOSE CONTACT" is defined as: household member, intimate partner, caregiver or having a face-to-face conversation for 10 minutes or more within distance of less than 6 feet.
Comment or Questions?
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Bella, the hypo-allergenic, non-shedding Maltese will join us for the weekend!
Home
Retreats
AUM Retreat
>
AUM resource page
Enrollment Agreement - AUM
Health Declaration - AUM
PAY NOW
Springhill Retreat Center
