Social Ride Pre-Screening Form

Social Ride Pre-Screening Form

Please complete this form for EACH social ride you plan to attend
Date of ride

Month Day Year
Date
Name

First Name Last Name
Date of Birth
Email
example@example.com
Please check YES or NO for each question or statement.
1. In the last 14 days, have you traveled internationally? *

No
2. In the last 14 days, have you or anyone you have had close contact with been diagnosed with COVID-19? *

No
3. In the last 14 days, have you or anyone you have had close contact with experienced any of the following symptoms?
- Fever, chills, or shaking
- Difficulty breathing
- New or worsening cough
- Sore throat
- Headache
- Muscle pain / aching throughout body
- Vomiting / diarrhea
- New loss of taste or smell
*

No
4. I agree to maintain at least 6 feet of distance between myself and others (not household members) whenever possible. *

Yes
5. I agree to wear a face covering whenever I cannot maintain a distance of at least 6 feet as described above, including when stopped on the trail. *

Yes
6. I agree to properly wash or sanitize my hands before handling items other than my personal property during the activity. *

Yes
7. I understand that, in the event that I am diagnosed with COVID-19 within 14 days after the date of this activity, it would be beneficial to my fellow members for me to inform the BVMBA Board of Directors of my diagnosis promptly (your identity will NOT be distributed to any members) . *

Yes
ATTESTATION:

My signature below certifies that the answers to the above statements are true and correct.
Signature

Clear
Date
Should be Empty:

Social Ride Pre-Screening Form

Please check YES or NO for each question or statement.