JCM/JG Covid Intake form

I understand the COVID 19 virus (including the Omicron, Delta, Lambda and B. 1. 621 variants) has a long incubation period during which carriers of the virus may not have symptoms and still be highly contagious. It is difficult/impossible to determine who has it and who does not, given limits in virus testing. Testing should be performed by a professional medical physician.

I confirm that I, and/or my child , am/are not presenting any of the following symptoms of COVID-19 listed below:

Temperature of 100 degrees or higher
Shortness of breath
Loss of sense of taste or smell
Dry cough
Sore Throat

Signature

Clear

Child's Name First Name Last Name

I confirm that neither I or my child have been around anyone with these symptoms in the past 14 days.

I do not live with anyone who is sick, quarantined, and/or suspected to have Covid 19.

To prevent the spread of contagious viruses and to help protect each other, I understand that I, my child, and guests have to follow JustHis Gymnastics Inc.'s/JustHis Christian Ministries, Inc's strict social distancing and safety protocol.

I understand that not social distancing significantly increases my risk of contracting and transmitting the COVID-19 virus. And I understand that the CDC, OSHA recommend social distancing of at least 6 feet.

Name

First Name Last Name

I verify that neither I or my child(ren) have traveled outside the United States in the past 14 days to countries that have affected by COVID 19.

I verify that neither I or my child(ren) have traveled domestically within the United States by commercial airline, charter bus, (Amtrack etc.) within the past 14 days.

Both I and my child understand that fitness gyms, indoor diners, and entertainment venues required proof of vaccination prior to March 7th 2022, for people 12 and up, before entering the facility. I understand that as if 3/7/22 proof of vaccination is no longer mandated by the state, but some business’ may require masks and even proof of vaccination.

Yes No

Vaccine Exemptions for people with Disabilities: Title I of the Americans with Disabilities Act (ADA) requires employers to provide reasonable accommodation to qualified applicants and employees with a disability. In some cases other medical conditions may prevent someone from being a candidate for the vaccine. Vaccine Exemptions for Religious reasons: Employers also have an obligation to accommodate an employee's sincerely held religious belief under Title VII of the Civil Rights Act (Title VII), Please provide your signature if you understand.

Clear

I understand that JustHis Gymnastics, Inc/JustHis Christian Ministries, Inc. maintains the right to refuse staff, parents, guests, and participants entrance/continued occupancy for the safety of all parties involved in the program.

Have you been vaccinated? (Optional)

Yes No Rather not say

Have you been tested for Covid-19? (Optional)

Yes No Rather Not say

Date

Participants Temperature (Taken before coming to the location)

Signature - confirming you acknowledge and accept the terms of this intake form

Clear