COVID-19 Health Screening

My Information:

First Name

Last Name

Phone Number

Diagnosis

I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks

Contact with Symptomatic

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks

Travel

I have not traveled outside of my immediate daily routine for the past two weeks

Symptoms

I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell

Contact Intrepid Staff

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Intrepid staff immediately

Follow Studio Rules

I will follow all posted studio rules to keep myself, my classmates and instructors, and those around me safe

Confirm Digital Signature

By adding your signature twice below, you confirm that the information above is accurate

Signed On