COVID-19 QUESTIONNAIRE
Full Name
*
First Name
Last Name
Phone Number
*
Email
example@example.com
Please complete the following questionnaire prior to entering the CoreBalFit Inc. location and show the confirmation page on your phone at check-in. By checking each box, you are confirming the following statements are true:
*
I have not, nor any member(s) of my household, knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19
I have not, nor any member(s) of my household, tested positive for COVID-19 through a diagnostic test in the past 14 days
I have not, nor any member(s) of my household, experienced any symptoms of COVID-19 in the past 14 days
I do not currently have a fever of 100.4 or higher
I have not, nor any member(s) of my household, traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 days
If you cannot affirm that all of the above statements are true, please do not come into the gym. You may return when you are able to affirm that all the above statements are true.
I CONFIRM
Should be Empty: