Retreat Signup

Name *

First Name

Last Name

Phone *

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The retreat is from 10-4 on Saturday, December 18. Can you make that whole time? *

Yes

No

Do you have any food allergies? *

Yes

No

Have you or anyone in your household had any of the following symptoms since Saturday, November 27: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, los of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?

Yes

No

Have you been vaccinated against COVID-19? (If you feel comfortable, please answer this question. It'll let us know overall how many folks are vaccinated, and if you are traveling in a car, some drivers may only feel comfortable driving people who are vaccinated.) *

I got my first vaccine shot of Moderna/Pfizer but not my second.

I got two shots of Moderna/Pfizer or one shot of Johnson and Johnson.

I got a booster shot (in addition to two shots of Moderna/Pfizer or one shot of Johnson and Johnson.)

I have not any gotten vaccine shots.

I prefer not to say.

During the retreat we will be in two spaces. In the first space (The City School), masks are required except for when we are eating breakfast -- people need to eat socially distanced. People also have to fill out a form online about COVID symptoms when they come, and help spray/wipe places we used. In the second space (VietAID), masks are required at all times and we cannot eat food inside. We'll also have guidelines around handwashing, hand sanitizers, social distancing, etc. Are you okay with this? *

Yes

No

We are meeting in Uphams Corner at 10 to eat breakfast inside of the office of The City School (a partner youth program), then traveling to Fields Corner for the rest of the retreat. Please say where you want to meet us and what your travel preferences are.

I'll meet you for breakfast in Uphams Corner, and I am okay either riding in a car or walking to the Savin Hill T to go to Fields Corner.

I'll meet you for breakfast in Uphams Corner, and I prefer riding in a car to Fields Corner.

I'll meet you for breakfast in Uphams Corner, and I prefer walking to Savin Hill T to go to Fields Corner.

I'll meet you for breakfast in Uphams Corner, and I can drive myself to Fields Corner.

I'll skip breakfast and meet you in Fields Corner.

For people who get a rides from us, we may require you to wear a K95 masks that is tighter fitting (which we will provide) while you are in a car. Is this okay with you?

Yes

No

We may some rides available but not for everybody after the retreat. Do you want or need a ride after the retreat?

No, I don't need a ride.

A ride would be nice but if I can't get one, I'll be okay.

I need a ride after the retreat.

Are you in school now? *

Middle school

High school

College / Training after high school

Not in school