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Health Declaration

The safety of our instructors and clients is our 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 entering the worksite. Please do not enter the worksite until your responses have been reviewed and your entry has been approved.

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 and instructors.

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)
Nausea, diarrhea, vomiting
Cough, Sore throat, Shortness of breath or difficulty breathing
New loss of taste or smell, Head or muscle aches and or Chills
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19 or who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?
Have you been tested for COVID-19 and are waiting to receive test results?
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?
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?
Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation.

Thanks for submitting!

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