Covid 19 Health Form

Date

Parent/ Gaurdian Full Name

First Last

Parent/ Gaurdian Cell Phone

Participant or Volunteers Name

First Last

This form should be completed on the day of your visit to Friendship Circle
If you are not visiting today, there is no need to complete this form .

Are you visiting Friendship Circle today?

Yes
No

What time do you plan to arrive?

:

If anyone in your household is symptomatic as described below you will not be able to participate in any activities at Friendship Circle.

Do you or your child have any symptoms, such as a temperature greater than 100 degrees, dry cough, difficulty breathing, fatigue, upset stomach or sore throat?

Yes
No

Is anyone in your household ill with symptoms including a temperature greater than 100 degrees, dry cough, difficulty breathing, fatigue, upset stomach, or sore throat?

Yes
No

Have you or your child come into contact with anyone who has tested positive for COVID-19 in the last 14 days?

Yes
No

I understand that all clients of Friendship Circle will be screened upon arrival for increased temperature and will not be allowed to participate in programming if they are symptomatic.

Yes
No

Waiver

Select All
I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days
I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 14 days.
I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 14 days.
I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 14 days.
I understand that Friendship Circle of Central Jersey cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each visitor.

Release Form

Select All
I understand that use of The Friendship Circle building, grounds and playground ("participation") involves a ceratin degree of risk and can be physically, mentally and emotioanlly demanding. I have carefully considered the risk involved and agree to allow my child(ren) to participate in these activities. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct as set forth by The Friendship Circle.
I understand that as an express precondition of my child(rens) participation that you acknowledge and agree that although The Friendship Circle cares deeply about the health and well-being of all participants or their gaurdians, I understand that The Friendship Circle cannot gaurantee that Covid-19 or any other viruses or disease will not be contracted by participants or their gaurdians.
I understand that The Friendship Circle is independantly owned and operated. In consideration of the oppurtunity to send my child to The Friendship Circle, and by enagaging in participation, I, myseld and behalf of my child, hereby agree to release, hold harmless and waive any and all claims against The Friendship Circle and its employees, directors, officers and volunteers as well as its affiliates and all other organizations associated with The Friendship Circle from any and all claims or liability arising out of this participation.
I understand that this form involves a release of legal rights.

The Friendship Circle is following these enhanced procedures to prevent the spread of COVID-19:

Conduct daily health assessments - Fill out the COVID-19 assessment form online each time you visit for indoor or outdoor play.
Temperature will be taken before entering any Friendship Circle Program
Face covering protocol- all parents and volunteers are required to wear a mask at all programs. Particpants are strongly encouraged to do so as well.
Maintain social distancing of 6 feet apart at all times.
Wash hands / sanitize frequently.
Disinfect areas as they are used.

By entering my initials below, I agree to each statement above and release Friendship Circle of Central Jersey from any and all liability for unintentional exposure or harm due to COVID-19.

Thank you for completing this screening today!

Covid 19 Forms

Title