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X-Fat Azz Cycling & Fitness Studio

COVID-19 PANDEMIC CONSENT FORM

as of 06.03.20

COVID-19 PANDEMIC CONSENT FORM

Due to the outbreak of the novel Coronavirus (COVID-19), X-FAT AZZ CYCLING & FITNESS STUDIO is doing everything we can to protect you, our clients, our community and our staff. To this extent, X-FAT AZZ CYCLING & FITNESS STUDIO will be following the Center of Disease-Control (CDC) and the Illinois Department of Financial and Professional Regulation guidance with regard to social distancing practices and sanitation. We ask that our clients disclose their health history and continue to implement these sanitation and disinfection procedures.

I knowingly and willingly consent to participate in fitness activities at X-FAT AZZ CYCLING & FITNESS STUDIO during the COVID-19 pandemic.


I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. 


I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of fitness activities, that I have an elevated risk of contracting the virus simply by simply being in the studio.


I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below:

Fever
Shortness of Breath
Loss of Sense of Taste or Smell
Dry Cough
Runny Nose
Sore Throat


To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the studio’s strict guidelines.

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus.  And I understand that the CDC recommends social distancing of at least 6 feet. 


I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19. 


I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days. 


First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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


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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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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