Staff Health Form

Staff Information
Staff's Name
Emergency Contact Information
2nd Emergency Contact Name OTHER than listed above:
Health Information

Status message

AT HOME HEALTH SELF ASSESSMENT:
The following questions you will need to ask yourself before coming to work.

  1.  Is my temperature above 100.4 degree F?
  2. Has anyone in the household had close contact with a confirmed COVID case in past 10 days without taking CDC procautions using proper PPE?
  3. Have I had a new cough, fever, chills, shortness of breath, body aches, congestion, runny nose, unusual headaches, fatigue, cough, sore throat in the last 48 hours?
  4. Have I had new loss of taste or small in the last 48 hours?
  5. Has anyone in my household had COVID-19 positive test or have possible Covid-19 in the last 14 days?
  6. Am I or anyone I have been in contact with, awaiting COVID test results?
If you respond yes to any of these questions please contact an administrator.

Please ensure you have washed you hands thoroughly before leaving home and upon returning home. Please wash your hands as soon as you arrive to the building and before you leave the building.

If yes, have you discussed your work with your Healthcare provider.
Immunization Information
Have you received the Covid-19 Vaccine?

Status message

If you will be within 6 feet for longer than 15 minutes with someone who has a suspected or confirmed case of Covid (this includes anyone you do not know) without taking proper precautions like wearing a mask and frequently washing your hands, please contact an administrator so that we can discuss your return to gym date. 

When at the gym, we require all staff members to follow our safety protocols  to mitigate the spread of germs and to help keep everyone safe. These include 1.) Staff must wear a mask 2.) Staff must do and pass a Health check self-assessment before coming to work 3.) Staff must keep students spread out 6 feet 4.) Staff must stay 6 feet apart, except for a safety spot of the student 5.) Staff must wash their hands before and after their shift as well as between classes 6.) Staff must sanitize facility between classes/practices  7.) Staff must immediately isolate any student not feeling well and contact an administrator.

When away from the gym for vacation or otherwise, we continue to ask you to be vigiliant and make smart choices in helping to mitigate the spread of Covid-19 and other viruses and germs.  Things that help with this include wearing a mask when inside or when you can not stay 6 feet apart at all times from others who are not vaccinated.  We remind you to frequently wash your hands.

Everyone has a responsibility to keep yourself and others safe.  We appreciate your efforts.

We are doing our best to protect everyone and to keep the gym free of Covid-19. 

We encourage all staff to get vaccinated to do their part in keeping everyone as safe as possble.

I understand that the coaches, administrators and owners as well as everyone at the gym will make a strong effort to mitigate the spread of Covid-19 and other germs and viruses. I know that even with increased sanitation and enhanced hygiene protocol, it is impossible to provide a completely sterile environment so the risk of Covid-19 exposure and other viruses may exist and I accept that risk.
I have been educated in the new enhanced sanitization procedures and fully understand them. I agree to follow all the sanitization and germ mitigating protocol.
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