Covid-19 Daily Pre-Screen • Dynamic Body Pilates

DBP Daily Pre-Screen Questionnaire

Full Name *

First

Last

In consideration of being allowed to participate on behalf of DBP programs and related events and activities, the undersigned acknowledges, appreciates, and agrees that: *

I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, headache, sore throat, new loss of taste or smell, among others;

#2 *

Travel Guidelines:

• I have not traveled within the last 14 days either internationally or out of New York.
OR
• I traveled and obtained a test within three days of departure from that state or country. Upon arrival in New York, I quarantined for three days. On day 4 of my quarantine, I obtained another COVID test. Both tests came back negative.

#3 *

I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19;

#4 *

I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities;

#5 *

If I have previously been diagnosed with Coronavirus/Covid-19, I have been cleared as non-contagious by state or local public health authorities;

#6 *

I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

If you cannot check all of the above boxes, please do NOT come to the studio. Your session can be done virtually instead. Any rescheduling must be done 24hrs prior to your session to avoid cancellation fees. Please contact DBP immediately at [email protected].

I have read each point and circumstance above and confirm that I have answered truthfully. *

Yes, I confirm.
No, I cannot confirm.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. *

Signature