THE CAC of HV & STUDIOCovid Screening Health Form (when requested)Participant(s)/Guardian may list up to (3) three participants. Please fill this form no earlier than 24-hrs. prior to the first visit of each week of studio time. * Required fields Date * MM DD YYYY Participant Name #1 * Participant Name #2 Participant Name #3 Cell Phone * (###) ### #### Self-Declaration by Participant/Parent/Guardian * Have you or the participant knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 YES NO Have you or the participant(s) tested positive for COVID-19 in the past 14 days? * YES NO Have you or the participant(s) experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)? * YES NO Have you traveled internationally or from a state with widespread community transmission of COVID-19 per the New York State Travel Advisory in the past 14 days. * YES NO Visitors answering yes to any of the above questions will not be permitted access to the studio facility. Visitors with a fever will not be permitted access to the building. * I Understand We require participants and parents/guardians to immediately disclose if and when their responses, or responses of their children, to any of the aforementioned questions changes, such as if they begin to experience symptoms, including during or outside of studio hours. * I Understand Parent/Guardian/Adult Participant Signature * You agree your electronic signature is the equivalent of your manual/handwritten signature. FOR INTERNAL USE: Access to facility YES NO Studio Signature Thank you for your submission. We look forward to see you!