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THE TOWN OF BEDFORD RECREATION AND PARKS

PROGRAM PRESCREENING QUESTIONS AND AGREEMENT

 

Participants Name ____________________________________ Program ____________________________

 

Declaration of Health

 

YES

NO

Has participant had any of the following symptoms over the past 14 days that are not caused by another condition?

 

i. Fever (temperature of 100.4 or above)

ii. Flu like symptoms (such as diarrhea, fatigue, chills, sore throat, nausea or vomiting, headache, cough)

iii. Shortness of breath or other difficulties breathing

iv. Loss of smell or taste

   

Has participant had close contact with anyone with confirmed COVID-19 in the past 14 days?

   

Has participant tested positive for COVID-19 in the past 14 days?

   

Has participant traveled to any states/territory on the NY restricted/quarantine list? (per the issuance of the Executive Order 205, eff. June 25, 2020) in the past 14 days?

 

https://coronavirus.health.ny.gov/covid-19-travel-advisory

   

Has participant traveled internationally (outside of the US) in the past 14 days?

   

 

Any participant answering yes to any of the above questions will not be permitted to attend the program until the 14 day observances are met.

 

 

 

 

 

 

 

Participant Agreement

 

Agree

Disagree

I agree that I will not attend program if I am experiencing any Covid-19 signs or symptoms. (Unexplained fever/no taste or smell, ect.)

   

Participant agrees that they have read the “Back to Programming Protocol” and agrees to abide by all regulations set within

   

I agree that if my family or I is exposed to someone with Covid-19 during the program that I will stay out of the program for the required 14 days.

   

Participant or designee must agree to the above in order to attend the Town of Bedford Recreation programs.

Participant Signature or Minors parent/guardian _____________________________ Date ______________

This form MUST be brought to the program for each clinic the participant attends.