Pop Up Tennis Kids Health Screening

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Please help us keep everyone safe by completing the health screening below for each person entering the gym.

電子郵件 *

Name of Person Entering Gym *

Do you currently have any of these symptoms? Please check all that apply. *

Fever or chills

Cough

Shortness of breath

Fatigue

Body aches

Headache

New loss of taste or smell

Sore throat

Runny nose/congestion

Nauseau/vomiting

Diarrhea

NO SYMPTOMS

必填

Have you had a positive COVID-19 test in the last 10 days? *

Yes

Have you or someone you live with been in close contact with someone who has a confirmed or suspected COVID-19 diagnosis in the past 10 days? *

Yes

Have you been mandated or advised by a government agency, physician or school to isolate or self-quarantine? *

Yes

Traveled in the past 2 weeks? Stayed home? Please choose the response that best matches your situation below. *

I have traveled and followed NY State guidelines for returning to NY safely and with the appropriate testing.

I have traveled and am awaiting clearance from tests taken.

I have not traveled.

Please certify that the above information is true by noting the first and last name of the person completing this form. *

將我的回應複本寄給我。

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