CPR Class Covid-19 Survey

This form must be completed within 24 hours of scheduled class. To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce  and visitors, we are conducting a simple screening questionnaire. Your participation is important and required to help us take precautionary measures to protect you and everyone in this building. Thank you for your time, consideration, and truthful responses.
COVID-19 Symptoms include:
-FEVER
-FATIGUE
-DRY COUGH
-DIFFICULTY BREATHING
-SORE THROAT
-BODY ACHES/PAINS
-HEADACHE

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* 1. Full Name

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* 2. Email

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* 3. Phone Number (XXX)XXX-XXXX

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* 4. Date of Birth MM/DD/YYYY

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* 5. Have you or anyone in your household currently have, or had experience the symptoms listed above in the last 14 days?

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* 6. Have you or anyone in your household, have been diagnosed with COVID-19 in the last 30 days?

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* 7. Do you give consent that your temperature be taken prior to your appointment as a precaution and for the safety of yourself and others?

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* 8. Do you understand that you must abide by any safety protocols and policies set forth by your Instructor or you could be refused service?

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* 9. You agree to reschedule if you were diagnosed with or exposed to someone diagnosed with COVID-19 within the 14 days of the appointment.

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* 10. You agree to reschedule if you experienced any cold or flu-like symptoms within 14 days of the appointment.

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* 11. You agree to wear a mask at the time of your appointment covering your nose and mouth at all times.

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* 12.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by my mere presence within this establishment and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families. I hereby release the booked business from any and all claims arising from or in connection with any direct COVID-19 impact while visiting.

By signing below, I agree to each above statement and release Education Connection Academy dba ECA Nonprofit and every instructor working at this location, (lessors) from any and all liability for the unintentional exposure or harm due to COVID-19 or any contaminants.

I Agree to all of the above.

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* 13. You agree to use Electronic Signature. Type your Full Name in the box to serve as your electronic signature.  

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* 14. Date of Signature.

Date
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