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A SINGLETRACK MIND COVID-19 SCREENING QUESTIONNAIRE

The safety of you and our clients is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to attendance. Please know your responses will be reviewed prior to your approved participation.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you, our employees, and other clients.

Date Signed: January 27, 2021

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Third Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Fourth Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Fifth Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Sixth Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Seventh Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Eighth Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Ninth Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Tenth Participant's Name

First Name*

Middle Name

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
CONSENT AND RELEASE OF PARENT OR GUARDIAN: I verify that I am the parent/guardian of the above named minor participant (under 18 years of age). I have authority to enter into this Agreement on behalf of the minor. I acknowledge and represent that my child is fit for the Activity and I consent to my child’s participation. I HAVE READ AND UNDERSTAND THE RELEASE OF LIABILITY AND WAIVER OF CLAIMS AND I UNDERSTAND THAT BY SIGNING THIS DOCUMENT I AM VOLUNTARILY WAIVING CERTAIN LEGAL RIGHTS AND WAIVING CERTAIN LEGAL RIGHTS ON BEHALF OF MY CHILD. In consideration for allowing my child to participate, I CONSENT TO THE AGREEMENT AND AGREE THAT ITS TERMS SHALL LIKEWISE BIND ME, MY CHILD, my heirs, legal representatives, and assignees. I am mentally sound and have capacity to enter in this Agreement, and that I enter into this Agreement of my own free will and accord, voluntarily, without coercion, duress, or undue influence from any source.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

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

Course: *

Representations

1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)*
Cough*
Shortness of breath or difficulty breathing*
Sore throat*
New loss of taste or smell*
Chills*
Head or muscle aches*
Nausea, diarrhea, vomiting*
2) In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
3) In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
4) Have you been tested for COVID-19 and are waiting to receive test results?*
5) Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?*
6) In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
7) In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

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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