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AZ ON THE ROCKS COVID-19 ENTRANCE SURVEY

&

ACKNOLWEDGMENT OF HIGH RISK FACILITY. 

(We cannot sanitize all the holds, ropes or harnesses on a frequent basis or in some cases at all) 

First Visitors Name

First Name*

Last Name*

Phone*
First Visitors Date of Birth*
First Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
First Visitors Signature*
Second Visitors Name

First Name*

Last Name*
Second Visitors Date of Birth*
Second Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Third Visitors Name

First Name*

Last Name*
Third Visitors Date of Birth*
Third Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Fourth Visitors Name

First Name*

Last Name*
Fourth Visitors Date of Birth*
Fourth Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Fifth Visitors Name

First Name*

Last Name*
Fifth Visitors Date of Birth*
Fifth Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Sixth Visitors Name

First Name*

Last Name*
Sixth Visitors Date of Birth*
Sixth Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Seventh Visitors Name

First Name*

Last Name*
Seventh Visitors Date of Birth*
Seventh Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Eighth Visitors Name

First Name*

Last Name*
Eighth Visitors Date of Birth*
Eighth Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Ninth Visitors Name

First Name*

Last Name*
Ninth Visitors Date of Birth*
Ninth Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
Tenth Visitors Name

First Name*

Last Name*
Tenth Visitors Date of Birth*
Tenth Visitors Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
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(s) are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Are you or anyone that you are around experiencing symptoms of COVID-19? (Including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat or loss of taste/smell)*
No
Yes
Have you or anyone that you have been around experienced any of the above symptoms in the past 14 days?*
No
Yes
Have you been practicing proper social distancing? (Stayed at least 6 feet from other people outside of home, have not gathered in groups of 10 or more, stayed out of crowded places and avoided mass gathering, used proper sanitization and hand-washing.)*
No
Yes
Do you have any cuts or open sores on your hands?*
No
Yes
Do you agree to follow new gym protocols as of May 18th, 2020?*
No
Yes
Although AZR has implemented extensive precautions in an attempt to minimize the chances of our visitors contracting Coronavirus (COVID-19), it is impossible to guarantee a virus-free facility. Indeed, even despite precautions, health clubs, including rock climbing facilities such as AZR, are considered high risk establishments because, among other factors, it is impossible to thoroughly and regularly disinfect every high touch surface and because of the number of visitors at the facility at any given time and/or over a period of time. By following posted mitigation protocols, you will hopefully help us reduce the changes of transmission. By entering our facility you acknowledge and accept the risk of spreading or contracting the virus. Do you agree?*
No
Yes
I confirm that if the above information changes, I agree to not visit the facility until I have met the qualifications established by the CDC, AND THAT I WILL CONTACT AZ ON THE ROCKS DIRECTLY TO INFORM THEM OF THE CHANGES.*
No
Yes
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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