COVID SCREENNG

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Daily COVID Screening.

Please complete the following form prior to attending ALL workouts

* Indicates required field

Name *

First

Last

Phone Number *

Today's Date *

HAVE YOU (PARTICIPANT) BEEN ILL WITH A FEVER, CHILLS, COUGH OR BODY ACHES IN THE LAST 14 DAYS? *

YES NO

HAS ANYONE IN YOUR HOUSEHOLD HAD THESE SYMPTOMS IN THE LAST 14 DAYS? *

YES NO

HAVE YOU OR ANYONE IN YOUR HOUSEHOLD TRAVELED INTERNATIONALLY IN THE LAST 14 DAYS? *

YES NO

HAVE YOU (PARTICIPANT) OR ANYONE IN YOUR HOUSEHOLD TRAVELED TO A LOCATION IN THE US WHERE AN INCREASE OF INCIDENCES OF COVID-19 HAS BEEN REPORTED IN THE LAST 14 DAYS? *

YES NO

HAVE YOU (PARTICIPANT) BEEN TOLD BY A HEALTHCARE PROVIDER THAT YOU SHOULD SELF-QUARANTINE DUE TO POTENTIAL COVID-19 EXPOSURE OR YOU ARE SUSPECTED OF HAVING COVID-19? *

YES NO

BY CHECKING THE BOX BELOW, YOU AGREE THAT YOUR STATEMENTS ARE ALL TRUE TO THE BEST OF YOUR KNOWLEDGE *

AGREE

Submit

info@simplyfitnow.com
215 801-7777

Home
membership
- Workout Passes
CLASSES
- descriptions
Nutrition
aqua
About
Contact