Health Screening
All students must complete this form EVERY CLASS DATE prior to the start of class.  Form is time/date stamped, so please do not submit early, as the date stamp must match the class date.
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Email *
Student Full Name *
Possible COVID-19 Symptoms
• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
Have you experienced any of the above symptoms in the past 14 days? *
Have you had a positive COVID-19 diagnostic test in the past 14 days? *
Have you been in or had any close contact with a confirmed or suspected COVID-19 case in past 14 days? *
Have you traveled out of state for longer than 24 hours within the past 14 days? *
I understand that if I selected "Yes" for any of the above questions, I may not participate in class or enter the Rampage Strength and Conditioning facility until enough time has passed that I can honestly and accurately answer "No" to all of the above questions, UNLESS I have been advised by the health department that I am cleared to exit quarantine. *
I certify that I have answered all of the above questions as accurately as possible and to the best of my ability.  I understand that purposefully providing false information may result in my removal from Rampage Strength and Conditioning's programming.
Electronic Signature *
A copy of your responses will be emailed to the address you provided.
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