JCA Health Screening Survey

Please submit this survey to complete your registration. In accordance with state health and safety guidelines, completed surveys will be required from each participant prior to each session in order to participate in JCA programs and activities.

First Name *

Last Name *

Email *

Phone *

Please complete all the survey questions below.

Have you had a cough or sore throat? *

Yes
No

Have you had a fever or do you feel feverish? *

Yes
No

Do you have shortness of breath? *

Yes
No

Do you have loss of taste or smell? *

Yes
No

Have you been around anyone exhibiting these symptoms within the past 14 days? *

Yes
No

Are you living with anyone who is sick or quarantined? *

Yes
No

Have you been out of state in the last 14 days? *

Yes
No

By completing and submitting this survey, you agree to the following waiver:

As a participant in the JCA’s fitness classes and activities, you agree and understand the following: You are aware that you agree to fully accept all known and unknown risks, including the potential risk of exposure to respiratory illnesses such as the coronavirus (COVID-19). The coronavirus is primarily transmitted via exhaled respiratory droplets, often through coughing and sneezing. You understand that you may be exposed to the coronavirus or its symptoms through no fault of the JCA. Known coronavirus symptoms include fever, coughing, shortness of breath, pneumonia, kidney failure, and may include other symptoms, stroke or even death (collectively "Symptoms"). You understand and agree that you will hold the JCA and our fitness instructors harmless and you will not hold us liable for any real or perceived symptoms of COVID-19 or any other disease, illness, or condition, nor for exacerbating any existing symptoms, and you fully agree to accept all risks of attending classes and/or interacting or being exposed to other participants.

Timeout Warning

JCA Health Screening Survey