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COVID-19 Attestation and Policy Guidelines

D-BAT COS and Pikes Peak Indoor Golf Center

8265 Jamboree Circle

Colorado Springs, CO 80920

Prior to coming into D-BAT Colorado Springs, all individuals will attest to the completion of screening questions and that they answer no to each of the questions.

Individual reviews screening signage and agree they have met the outlined criteria.

If indiviual is asymptomatic and answers yes to any of the questions, they can not come into D-BAT or Pikes Peak Indoor Golf Center, or if they are here they must leave immediately.

To reduce the risk of spreading COVID-19, below you will be asked several “screening” and "contact tracing" questions. For the safety of our staff, clients, customers, and yourself, please be truthful and candid in your answers.

Our facility complies with the State Health Department and the Centers for Disease Control guidance and directives to help prevent the spread of the COVID-19 virus, but we cannot make any guarantees.

First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
First Clients Signature*
Second Clients Name

First Name*

Middle Name

Last Name*
Second Clients Date of Birth*
Second Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Third Clients Name

First Name*

Middle Name

Last Name*
Third Clients Date of Birth*
Third Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Fourth Clients Name

First Name*

Middle Name

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Fifth Clients Name

First Name*

Middle Name

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Sixth Clients Name

First Name*

Middle Name

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Seventh Clients Name

First Name*

Middle Name

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Eighth Clients Name

First Name*

Middle Name

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Ninth Clients Name

First Name*

Middle Name

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Tenth Clients Name

First Name*

Middle Name

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
No
Yes
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
brian@dbatcos.com
1. The above answers are true and correct to the best of my knowledge, 2. I will abide by all D-BAT rules regarding wearing of face coverings, adhering to physical distancing and area hygiene, 3. I may be asked to leave if I present symptoms related to COVID-19
I attest to the above policy guidelines:*
No
Yes
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Insert current date of answers *
Have you had any of the following symptoms in the last 24 hours (not related to hay fever, seasonal allergies, other other known condition)? 1. Fever or chills, 2. Shortness of breath or difficulty breathing, 3. Muscle or body aches, 4. New loss of taste or smell, 5. Sore Throat, 6. Congestion or runny nose, 7. Vomiting, 8. Diarrhea*
No
Yes
Have you been in contact (within 6 feet > 15 minutes), or caring for someone who has diagnosed with COVID-19 in last 14 days?*
No
Yes
Have you been diagnosed with COVID-19 in the last 10 days or been told you need to isolate or quarantine by your work, school, or etc.?*
No
Yes
Have you traveled outside the United States by air or cruise ship in the past 14 days?*
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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