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?

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

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

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?

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

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

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

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

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

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

Covid-19 Screening Survey and Waiver

Screening Survey

Covid-19 Waiver and Release