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YR JIU JITSU TEAM Participation Waiver in Martial Arts and Fitness Private lessons, Group Classes, Seminars, Open Workouts and Open Mats.


I hereby am choosing to continue my training at  Crave Fitness Inc, DBA YR JIU JITSU TEAM. I understand that there are risks associated with my participation and I fully accept and release the owner Yaniv Rosenberg and the staff at Yaniv Rosenberg Jiu Jitsu Team from any responsibility related to any likelihood of contracting COVID-19 during today's visit. I fully confirm that I have not tested positive for COVID-19 nor do I have any symptoms currently related to COVID-19. I am also truthfully stating that I have not traveled outside the US in the last 4 weeks, nor have had any contact with anyone who may have any symptoms concurrent with COVID-19, including but not limited to to fever, cough, nausea, diarrhea, vomiting, shortness of breath, etc.

 

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Do you have any flu like symptoms? Fever? Chills? Cough? Shortness of breath? Body Aches?*
No
Yes
Do you have a significant chronic illness?*
No
Yes
Do you have a compromised immune system?*
No
Yes
Have you traveled to a location with a level 3 travel health notice in the past month?*
No
Yes
Have you traveled in an airplane the past two weeks?*
No
Yes
Have you been previously asked to self isolate or self-quarantine?*
No
Yes
Have you had close contact to an individual diagnosed with the COVID-19 infection?*
No
Yes
Have you been recently tested for COVID-19?*
No
Yes
If yes, have you received results that you tested positive for COVID-19?*
No
Yes

Any other medical history changes? Please clarify in the space below:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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