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Please complete this form just prior to your arrival at the museum.  This form will be collected at the museum Medical Screening Area prior to temperature assessment.

In order to address guest and employee safety and mitigate (as much as possible) potential exposure to COVID-19, the Indianapolis Motor Speedway Museum requires daily screening for COVID-19 symptoms.

1. I have not had a NEW or worsening cough, sore throat, shortness of breath, nausea, vomiting, diarrhea, muscle aches (not associated with strenuous physical activity) in the past 14 days.

I Agree

 

2. I have not had a fever of 100°F or higher in the past 72 hours.

I Agree

 

3. I have not felt feverish or had chills in the past 72 hours.

I Agree

 

4. I have not experienced a new loss of taste or smell.

I Agree

 

5. I have not recently been in close contact (less than 6 feet) with anyone experiencing symptoms as mentioned above or who has tested positive for COVID-19. Or I have been in contact with COVID-19 patients becuase I am a healthcare provider, but was wearing approproate PPE the entire time.

I Agree

First Customer's Name

First Name*

Last Name*
First Customer's Date of Birth*
I certify that I am 18 years of age or older
First Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
First Customer's Signature*
Second Customer's Name

First Name*

Last Name*
Second Customer's Date of Birth*
Second Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Third Customer's Name

First Name*

Last Name*
Third Customer's Date of Birth*
Third Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Fourth Customer's Name

First Name*

Last Name*
Fourth Customer's Date of Birth*
Fourth Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Fifth Customer's Name

First Name*

Last Name*
Fifth Customer's Date of Birth*
Fifth Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Sixth Customer's Name

First Name*

Last Name*
Sixth Customer's Date of Birth*
Sixth Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Seventh Customer's Name

First Name*

Last Name*
Seventh Customer's Date of Birth*
Seventh Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Eighth Customer's Name

First Name*

Last Name*
Eighth Customer's Date of Birth*
Eighth Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Ninth Customer's Name

First Name*

Last Name*
Ninth Customer's Date of Birth*
Ninth Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Tenth Customer's Name

First Name*

Last Name*
Tenth Customer's Date of Birth*
Tenth Customer's Team or Affiliation (If Applicable)

Enter team name or affiliation
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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 Team or Affiliation (If Applicable)

Enter team name or affiliation
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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