COVID-19 Health Screening Form

Covid-19 Health Declaration

Complete this form for each person who will enter the building. Reminder: only students will be allowed in the building. The student's teacher will escort the student to and from class.

Please submit this on the day of your lesson. Forms submitted at any other time will not be accepted.

Student's First Name

Student's Last Name

Teacher's Name

My body temperature is lower than 100.5°F/ 38°C

I am not experiencing the symptoms: fever, chills, cough, sore throat, shortness of breath, nasal congestion, body aches, loss of taste/smell, diarrhea, nausea, or vomiting

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I haven't traveled out of the country or state in the last 14 days.

Your First Name (If you are not also the student)

Your Last Name (If you are not also the student)

Your Initials

Date

I have read and acknowledge the following: In consideration of myself and/or my children being allowed usage of the MACC property or facility during the COVID-19 pandemic and for other good and valuable consideration, receipt of which is hereby acknowledged, on behalf of myself, my children and all others who may claim by, under, or through myself I do hereby agree to indemnify and hold harmless and do hereby release, acquit, and forever discharge the MACC, SMEPF, and the Town of Signal Mountain and all of its officers, employees, agents and assigns, and all other persons or companies from any and all claims, actions, or causes of action which I and/or my children now have, or which may hereafter accrue, whether for personal injury or property damage, whether known or unknown, arising out of or in any way resulting from my and/or my children’s usage of any MACC property or facility during the COVID-19 pandemic. I understand and agree that clicking submit below represents a signature on behalf of myself and each of my children.

I declare that the info I’ve provided is accurate & complete

Thanks for submitting! We'll see you later today!

Covid-19 Health Declaration

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Mountain Arts Community Center