COVID-19 Health Screening

Home COVID-19 Health Screening

COVID-19 Health Screening Questions

For the safety of all and in accordance to what is mandated by New York State, we are asking all members and employees to conduct a self-evaluation Health Assessment before visiting Riverwalk Athletic Club. Please note this questionnaire is conducted on an honor basis and all information in the questionnaire will be kept confidential unless it’s legally required by Health Authorities in the event of a concern.

Please read the 4 questions below carefully and answer each one honestly: check YES or NO.

1. Do you have any of the following symptoms: fever, new or existing dry cough, difficulty breathing, fatigue and loss of taste or smell?*
- Yes
- No
2. Have you or any other household member tested positive for COVID-19 in the past 14 days?*
- Yes
- No
3. Have you or any other household member had close contact with a confirmed or suspected COVID-19 case in the past 14 days?*
- Yes
- No
4. Have you traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 days?*
- Yes
- No
If you answered yes to any of the above questions, you will be denied access to the club.
Employee Declaration
- Staff will wash/sanitize hands before and after their shift and at regular intervals during their shift.
- Staff will physically distance themselves 6 feet from members and other staff members when standing or sitting in one place.
- Staff will have limited-to-no contact with members and other staff members
- Staff will wear masks at all times and wear gloves when cleaning
Participant Declaration
As a member you are responsible for practicing good facility hygiene and following mandated protocol during each visit:
- Scan in each time upon arrival
- Wipe down equipment before and after use
- Wash hands before, during, and after workouts
- Practice social distancing in all areas of the club. If spotting is needed, it must be conducted in the least amount of time possible (i.e., no lingering).
- Wear acceptable face covering at all times (bandanas, buffs, and gaiters not acceptable) other than while in the pool
Acknowledgment and Understading*
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid only for the day it is completed and a new one must be submitted for each day when visiting the club as a member or employee. I also acknowledge that Riverwalk Athletic Club is required to retain a copy of this form for at least 28 days per state mandate. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

Riverwalk Athletic Club has put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you will not become infected with COVID-19. 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 attending Riverwalk Athletic Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind.
- Yes, I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire.
Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Phone*
Date*
Date Format: MM slash DD slash YYYY
Digital Signature*

COVID-19 Health Screening

COVID-19 Health Screening Questions

Employee Declaration

Participant Declaration