Starlite Station COVID-19 Disclosure, Consent & Contact Tracing Form
This customer disclosure form seeks information from you that we must consider before making decisions in the circumstance of the COVID-19 virus and is paramount for contact tracing purposes. A weakened or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us. It is important that you disclose to the Starlite Station Management any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus. Other customer expectations include self-sanitizing dining area, just as you would at a workout gym, our restaurant asks that customers sanitize their dining area's tables, chairs, commonly touched surfaces, and any other surfaces that could potentially have been touched. Thank you for your continued support for our establishment and team. - Management
Name
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First Name
Last Name
Today’s Date
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-
Month
-
Day
Year
Date
Email
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example@example.com
Cell Phone Number
Please enter a valid phone number.
Do you have a fever or above normal temperature?
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YES
NO
Have you experienced shortness of breath or had trouble breathing?
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YES
NO
Do you have a dry cough?
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YES
NO
Do you have a runny nose?
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YES
NO
Have you recently lost or had a reduction in your sense of smell?
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YES
NO
Do you have a sore throat?
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YES
NO
Have you been in contact with someone who has tested positive for COVID-19?
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YES
NO
Have you tested positive for COVID-19 within the past 14 days?
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YES
NO
Have you been tested for COVID-19 and are awaiting results?
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YES
NO
Have you traveled outside Colorado in the past 14 days?
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YES
NO
Have you traveled outside the United States in the past 14 days to countries that have been affected by COVID-19?
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YES
NO
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible at the Starlite Station due to the nature of the Socially-Interactive Service Industry.
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I Understand
I Do Not Understand
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not give the current limits in virus testing
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I Understand
I Do Not Understand
Socially interacting with others at the Starlite may spread bodily fluids in the air or on other individuals. It is unclear as to how long the ultra-fine nature of the bodily fluids may linger in the air, which can transmit the COVID-19 virus.
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I Understand
I Do Not Understand
I understand that dancing requires more respiratory usage, which may increase likelihood of the spread of COVID-19 and COVID-19 Variants.
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I Understand
I Do Not Understand
I have been Fully Vaccinated with an FDA Approved Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vaccine.
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Yes
No
I understand that dancing may involve aerial or non-aerial exercises and movements of yourself or others, and may result in bodily harm.
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I Understand
I Do Not Understand
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.
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I FULLY understand and acknowledge ALL of the above information.
I DO NOT FULLY understand and/or acknowledge the above information.
By signing this document, I acknowledge that the answers I have provided above are true and accurate. I knowingly and willingly consent to Dining-In at the Socially-Interactive Dancing Venue called the Starlite Station during the COVID-19 pandemic.
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I Agree
I Disagree
Signature
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Submit
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