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Today's Date: June 10, 2023

PRE-SHIFT EMPLOYEE & ENTERTAINER COVID-19 SCREENING QUESTIONNAIRE

Upon arrival at the workplace, take each employee or entertainer’s temperature using the hand thermometer. Make a visual inspection of the individual for signs of illness, which could include flushed cheeks or fatigue, and ask the following questions:

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 Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 Information

In the past 24 hours, have you experienced: 

Fever*
No
Yes
Fatigue*
No
Yes
Chills*
No
Yes
Cough*
No
Yes
Sneezing*
No
Yes
Loss of Smell or Taste*
No
Yes
Muscle Aches and Pains*
No
Yes
Sore Throat*
No
Yes
Shortness of Breath*
No
Yes
Diarrhea*
No
Yes
Headaches*
No
Yes
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes

I attest that the foregoing information is true and correct. I further understand and accept that Camelot Social Club and its affiliated entities Camelot Social Club LLC, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against Camelot Social Club, or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment. 

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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