Essence Yoga COVID-19 Consent/ Screening Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please take a moment to fill out our Screening/ Consent Form. By submitting the form below, you agree to willingly practicing yoga/ fitness during the COVID-19 Pandemic. We reserve the right to refuse service if this form is not submitted. Thank you.

First and Last Name *

Phone Number *

What is today's date? *

YYYY

Have you presented any of the following symptoms in the last 3 days? (cough, shortness of breath, fever or chills, muscle or body ache, sore throat, headache, nausea or vomiting, diarrhea, runny or stuffy nose, fatigue, loss of taste or smell) *

I have not presented any of the listed symptoms.

Required

Today my temperature is... *

If I was unable to take my temperature, I agree to allow Essence Yoga to take my temperature upon arrival.

I agree.

Clear selection

I verify that I have not been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days. *

Yes.

I verify that I have not traveled anywhere outside the 50 United States in the past 14 days. *

Yes.

I verify that I have not traveled to Rhode Island for a non-work-related purpose from another city, town, county, or state that currently has a stay-at-home restriction, a shelter-in-place restriction, or a similar restriction due to a COVID-19 outbreak. *

Yes.

I verify that I have not been directed to quarantine or isolate by the Rhode Island Department of Health or a healthcare provider in the past 14 days. *

Yes.

To prevent the spread of the virus and to help protect others, I agree to follow Essence Yoga's guidelines. *

I agree.

I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of fitness, that I have an elevated risk of contracting the virus simply by being in the studio. *

I understand.

*Digital Signature* Please type your full name below. By typing and submitting, this serves as a Digital Signature and verifies that you fully agree to our safety policy for our services. This digital signature holds the same authority as a handwritten one. Thank you! *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms