Medeo Fencing COVID-19 Questionnaire (DAILY)

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This questionnaire is intended to screen students prior to the start of every private lesson or group class.

Student Name *

Today's Date (date you are coming in for practice) *

YYYY

What is your current body temperature? (If you do not have a personal thermometer write "NONE" that below) *

Have you or anyone in your household had a fever or other Covid-19 symptoms (no matter how minor) in the past 14 days? (e.g. Fever, Cough, Shortness of Breath, Sore Throat, Congestion, Headache, Muscle and Joint Pain, Chills, Nausea or Vomiting, Diarrhea) *

Yes

If you answered 'Yes', please elaborate on what symptoms:

Have you or anyone in your household tested positive with Covid-19? *

Yes

If 'Yes', please elaborate on who and when they tested positive.

Have you or anyone in your household been in close contact with someone who tested positive with Covid-19 within past 14 days? *

Yes

Are you or anyone in your household waiting for Covid-19 test results? *

Yes

Have you or anyone in your household used transportation open to the public in the past 2 months (e.g. buses, Uber, planes)? *

Yes

If 'Yes', please elaborate where you went and when.

Have you or anyone in your household commuted to NYC for work or traveled out of state in the past 2 months? *

Yes

Please list any places you visit on a regular basis (e.g. schools, shopping centers, office buildings) *

Please list any places you visited in the past two weeks (14 days) that are not on a regular basis (e.g. New York City, doctor’s office) *

Check all the measures you agree to abide by in order to begin practicing at Medeo Fencing Club: *

I will come to Medeo Fencing Club already dressed in freshly washed workout clothing

I will practice social distancing (staying 6 ft away from other students, coaches, staff)

I will wash hands with soap and warm water and/or sanitize my hands at least every 30 minutes

I will avoid touching my face, eyes, mouth with unclean hands

If I have to cough or sneeze I will do so into my elbow

If I show any symptoms of COVID-19 I understand that I must quarantine for 14 days (do not come into Medeo for 14 days)

I will use a face mask at all times within Medeo Fencing Club, even under the fencing mask

I will avoid communal equipment. If I use any shared equipment I am prepared to disinfectant anything that I use

I will not share my equipment with others

I will take my uniform and equipment home after each lesson and/or class. I will NOT leave my fencing bag at Medeo

I will not stay in Medeo longer than my allotted lesson and/or class time

My parent(s) will stay in the car and wait for me until I finish my lesson and/or class

If a coach or Lisa finds my behavior in breach of any of the listed items, I understand that I am at risk of being temporarily suspended from entering Medeo Fencing Club

Required

Electronic Signature: By signing with an e-signature (type your first and last name) below, I certify that the information provided in the form is true and accurate and understand the consequences of any misconduct that threatens the health and safety of myself and others. *

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