Health Screening

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* 1. Name:

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* 2. Do you or anyone you live with have a cough (varying from baseline), sore throat, fever, flu like symptoms, new loss of taste, smell or shortness of breath?

Yes

No

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* 3. In the last 8 hours have you taken fever reducing medication?

Yes

No

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* 4. If you answered yes to any questions we kindly ask that you reschedule your class for a later date.

-

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* 5. By checking the box below, I acknowledge that I meet the necessary health + safety requirements outlined above and

I confirm that I:
HAVE NOT been directed by a government entity to self- quarantine as a result of travel
HAVE NOT been in contact with a confirmed COVID case for over 14 days and am not currently under review in the contact tracing of a confirmed case
HAVE NOT been directed to self-quarantine, and HAVE NOT had contact with anyone who has been directed to do so
DO NOT currently have fever, chills, cough, sore throat, repeated shaking w. chills, new loss of taste or smell or shortness of breath?

Yes, I acknowledge the statement above

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* 6. You are participating in The Refinery Fitness group fitness classes at your own risk. Please be advised that there may be risks in being in the proximity of others. We are taking precautions to limit the spread of disease, yet there is still a possibility of transmission. By checking the box below, you understand the risks associated with attending classes and release The Refinery Fitness of any liability associate if you were to become sick.

Yes, I acknowledge the statement above

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* 7. Signature:

Name

Date