Covid-19 Screening Survey and Waiver

Student Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you or traveled outside of the USA in the last 14 days?*

YesNo

Have you or traveled within the USA in the last 14 days?*

YesNo

Have you been on a cruise ship in the last 14 days?*

YesNo

Have you and/or a member of your household been in close contact with anyone who has traveled domestically or internationally in the last 14 days?*

YesNo

Have you attended any events or gatherings with more than 100 people?*

YesNo

Have you been in close contact with a person known to have the 2019 Novel Coronavirus?*

YesNo

Have you and/or a member of your household been asked to self-quarantine?*

YesNo

Do you currently have fever or lower respiratory symptoms such as a cough or shortness of breath?*

YesNo

Do you have a new onset of cold symptoms such as a cough and runny nose?*

YesNo

By signing this form below, I acknowledge that it is my responsibility to ensure my own safety and well- being by practicing social distancing throughout the class. I do not hold PRP Firearms LLC, PRP Training Solutions, ShootingClasses.com, Brian Holmes, or any parties associated with them liable for any illnesses I may acquire.

Signature*

Date*

Date

Covid-19 Screening Survey and Waiver

Screening Survey

Covid-19 Waiver and Release