Request edit access
Wah Lum Consultation Health Screening
Please answer the questions in order to assist us with continuing to provide a safe training environment. We respect your privacy. By filling out this form you agree to wear a mask to your consultation and observe distancing from others.
Sign in to Google to save your progress. Learn more
Email *
Which classes are you interested in? *
Required
Has anyone planning to visit the Temple for the consultation recently been infected with covid19 or been in contact with anyone who has tested positive for covid19 within the past 2 weeks? *
Does anyone planning to visit the Temple have any symptoms of a virus or illness? (such as but not limited to: fever, coughing, shortness of breath, fatigue, muscle soreness, sore throat, runny nose, nausea, etc.) *
Have you received the covid19 vaccine? *
For KIDS/LM class: Has your child received the covid19 vaccine? *
The following section is in regards to your comfort levels while training.
I would feel comfortable training OUTDOORS WITHOUT distance restrictions and WITHOUT a mask. (no physical contact with others) *
I would feel comfortable engaging in partner work: self defense/contact drills/bagwork with other students or instructors: (physical contact involved) *
I would agree to show proof of my vaccination to the Wah Lum administration to participate in classes involving physical contact and limited distancing. *
By typing my full name below, I agree this acts as my official signature. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy