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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Email Address*
12. DOB*
    DOB
13. Gender
15. Phone number*
16. Date of positive COVID-19 test*
    Date of positive COVID-19 test
17. COVID-19 test brand name/type*
19. Use the button below to upload a photo of your POSITIVE test result only. Legibly write the individuals name, the date, and the time the test was taken directly on the test. Max file size: 5 MB. Allowed file types: JPG, JPEG, GIF, PNG.*
21. I attest that the information on this form and the attached positive test result is mine or my minor child whose name is listed. All information is true and accurate. Signed:*

    To find a testing location visit: https://coronavirus.health.ny.gov/find-test-site-near-you

    Once you submit this form you may proceed to print the AFFIRMATION OF ISOLATION. 

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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

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