Center Day Family Camp - Health Screening Survey

CDC Health Screening Survey

First Name *

Last Name *

Email *

Phone *

Please complete all of the survey questions below:

Have you had a cough or sore throat? *

Yes

No

Have you had a fever or do you feel feverish? *

Yes

No

Do you have shortness of breath? *

Yes

No

Do you have loss of taste or smell? *

Yes

No

Have you been around anyone exhibiting these symptoms within the past 14 days? *

Yes

No

Are you living with anyone who is sick or quarantined? *

Yes

No

Have you traveled out of state (excluding New Hampshire and Vermont) in the last 14 days? *

Yes

No

By completing and submitting this survey, you agree to the following waiver:

As a participant in JCA classes and activities, you agree and understand the following: You are aware that you agree to fully accept all known and unknown risks, including the potential risk of exposure to respiratory illnesses such as the coronavirus (COVID-19). The coronavirus is primarily transmitted via exhaled respiratory droplets, often through coughing and sneezing. You understand that you may be exposed to the coronavirus or its symptoms through no fault of the JCA. Known coronavirus symptoms include fever, coughing, shortness of breath, pneumonia, kidney failure, and may include other symptoms, stroke or even death (collectively "Symptoms"). You understand and agree that you will hold the JCA and our fitness instructors harmless and you will not hold us liable for any real or perceived symptoms of COVID-19 or any other disease, illness, or condition, nor for exacerbating any existing symptoms, and you fully agree to accept all risks of attending classes and/or interacting or being exposed to other participants.