off-site trip REQUEST

This form should be completed whenever residents in Assisted Living, MyTapestry or the Healthcare Center would like to leave campus for medical or non-medical outings.
This form must be completed at least 48 hours prior to the outing.

* All fields and answers are required:

Time of Outing

All trips off-campus must comply with the following expectations. The resident will be evaluated upon return from the outing. If the resident shows any signs or symptoms of COVID-19 or if any of the below conditions were not maintained, the resident may be placed on quarantine precautions for 14 days upon return.

Please carefully review the following expectations during outing:

Resident and those assisting them are to perform frequent hand-hygiene while at the destination
Resident and those with whom they come in contact will continuously wear a face covering
Resident is to maintain six feet of separation from other individuals while at destination

By checking this box I affirm that the above expectations will be followed during the requested outing.

Thank you.
Your request has been delivered.

(309) 557-8000

601 Lutz Road,

Bloomington, Illinois 61704

off-site trip REQUEST