I, [NAME], a resident of [BOROUGH], hereby certify that I am leaving my apartment/brownstone/co-op (circle one) to do the following and ONLY the following:

Circle all that apply

• To Purchase Groceries and/or Pick Up Prescriptions
• To Walk the Dog and/or Very Social Cat
• To Tend to the Community Garden and/or Refill Growler at Local Craft Brewery
• To Seek Medical Treatment and/or Marijuana
• OR: I Certify That I Am Required to Travel For My Job and/or Grindr Hook Up

My destination is limited to the following neighborhood:

Circle one based on income bracket

• Whichever Neighborhood Has the Nearest Foodtown
• Whichever Neighborhood Has the Nearest Trader Joe’s
• Whichever Neighborhood Has the Nearest Whole Foods
• Whichever Neighborhood Has the Nearest Hampton Jitney
• Whichever Neighborhood Has the Nearest Helipad

In order to prevent and track community spread, I will document any and all modes of travel, including:

Circle all that apply

• Walking
• MTA Bus (indicate route)
• MTA Subway (indicate line)
• CitiBike (indicate whether you licked the handlebars)
• Uber/Lyft/Taxi (indicate whether you racially profiled the driver when he coughed)

In addition to all of the above, I hereby assert that I am healthy enough to leave the home and have taken my temperature either with a digital thermometer or by asking a stranger to touch my forehead.

By signing this document I agree to self-report any symptoms, including but not limited to:

Circle all that apply

• Dry Cough
• Wet Cough
• Moist Cough
• Oh, This Cough? I Always Have This Cough

If I am under the age of 18 this document serves as parental certification that I have completed at least 5 tabs of remote learning and/or Twitch streams before leaving the house.

As a reward I have given permission for the following activity:

Parent/Guardian: Circle and initial only ONE per day

• Just Chillin
• Makin Tik Toks
• Subway Dance Practice
• Doing Those Drugs From HBO’s Euphoria
• Anything That Gives Mommy and/or Daddy Some Alone Time

IMPORTANT: If I develop COVID-19 symptoms while in public I give emergency responders permission to take me to:

Circle one based on health coverage

• The nearest hospital best equipped to treat me
• The nearest in-network hospital least likely to gouge me with surprise fees
• The nearest City MD but only if I have enough cash to cover the co-pay
• The nearest Walgreens so I can ask the pharmacist if Wal-Tussin cures coronavirus
• The nearest Canadian border crossing

SIGN HERE:

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Friendly Reminder: The NYPD may stop you and frisk your person for this form at any time (unless you’re white).