Covid-19 Student Health Questionnaire

Name *

First

Last

Email *

Required to ensure we're able to send notifications regarding the class

Phone

Recommended in event the Twirly Team is trying to contact you regarding the class session

Scheduled Date of Class *

Date planning to be onsite at the studio

Class

In the past 24hrs, have you experienced any symptoms of Covid-19? *

Covid-19 Symptoms include: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea

In the past 14 days, have you been exposed to anyone known to have Covid-19 or anyone who appears to have Covid-19 symptoms? *

Covid-19 exposure includes close physical contact (6 feet or closer for at least 15 minutes)

Are you currently self-quarantining because you may have been exposed to a person with Covid-19 or worried you may be sick? *

Are you or someone you live with currently waiting on the results of a Covid-19 test? *

Comments

If you have answered Yes to any of the answers above, please share any comments regarding your response to the Twirly Team prior to arriving onsite

ToS_Covid *

I have read and agree with the Release of Liability Agreement Listed Below *

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19.

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Twirly Tribe Studios, LLC has put in place preventative measures to reduce the spread of COVID-19; however, Twirly Tribe Studios CANNOT guarantee that you will not become infected with COVID-19. Further, attending events onsite at Twirly Studios in Pleasanton could increase your risk of contracting COVID-19.

By accepting 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 visiting Twirly Studios 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, Twirly Tribe Studios employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury I incur (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance onsite at Twirly Studios or participation in Twirly Tribe Studios programming (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Twirly Tribe Studios, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Twirly Tribe Studios, its employees, agents, independent contractors, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Twirly Tribe Studios class, program, workshop or event.