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COVID-19 Pre-Visit Self Screening - Declaration

 

Today's Date:
June 13, 2021

 

This form must be completed one time in advance to your first class back to the dojo.

By completing this form, you are helping us lower the risk for COVID transmission, keeping the gym safer for other members and our staff. If you do not complete this form, you will not be permitted to attend class.

Thank you for understanding.

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
COVID-19 Symptoms

COVID-19 Symptoms include fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue, and loss of appetite. People infected with COVID-19 may also experience gastrointestinal symptoms like diarrhea, nausea and vomiting a few days after the onset of the above symptoms.

1. Are you currently experiencing any of the above symptom(s) associated with COVID-19?*
No
Yes
2. Have you experienced any of the above symptoms associated with COVID-19 in the past 14 days?*
No
Yes
3. Have you travelled internationally within the past 14 days?*
No
Yes
4. Has anyone in your household experienced these symptoms in the past 14 days?*
No
Yes
5. Have you or anyone in your household been tested for COVID-19 and are waiting for results?*
No
Yes

Thank you for completing the self-screening questionnaire. If you answered yes to any of the above questions, your coach will contact you. See you soon!

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*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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