Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below.

Symptoms of COVID-19 include:

Fever
Fatigue
Dry cough
Difficulty breathing

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.

Name

First Name

Last Name

Date

YYYY

By signing below I agree to each of the above statements and release Joe Sulak and Peak Fitness from any and all liability for the unintentional exposure or harm due to COVID-19. *

I agree to all of the above statements. Acknowledging this represents my signature.