Mandatory Self-Health Questionnaire
Before participating in one of Butterfly Kids Yoga in-person activities, you are required to evaluate your health and your child’s (or children’s) health by completing the following Self-Health Questionnaire. This form must be handed in prior to participating.  This is a NYS requirement.
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Email *
Name *
Your phone number *
Your child's name (or children) *
You are required to answer all questions and you must respond YES to all questions in order to participate.
I confirm that I (and on behalf of my child) have not tested positive for COVID-19 in the last 14 days. *
Required
I confirm that I (and on behalf of my child) have not been in close physical contact with anyone who is either confirmed or suspected to be infected with COVID-19 in the last 14 days. *
Required
I confirm that I (and on behalf of my child) have not traveled in the last 14 days to any location that New York State has designated as requiring a 14-day self-isolation after returning due to high incidence of COVID-19. *
Required
I confirm that I (and on behalf of my child) have not experienced any symptoms associated with COVID-19 in the past 14 days.  If I have experienced any symptoms I have discussed my symptoms, as listed below, with my doctor (or my child’s doctor) and have confirmation they are not related to COVID-19.  The symptoms are:  Fever (>= 100.4 degrees Fahrenheit, Cough, Shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle Pain, Headache, Sore Throat, New Loss of Taste or Smell. *
Required
By submitting this form, I attest this information is true and accurate.
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